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Članek prispel / Received
28. 4. 2024 
Članek sprejet / Accepted
4. 6. 2024
Abstract
Purpose: In Slovenia, the transition 
from paper-based to electronic sick 
leave certificates (hereafter referred to 
as eBOLs) started at the beginning of 
2020. While paper sick leave certifi-
cates are still widely used worldwide, 
many European countries are already 
reaping the benefits of using the eBOL 
system. This survey aimed to deter-
mine patients’ satisfaction with the 
new eBOLs and highlight the most 
significant advantages and disadvan-
tages from the patient’s viewpoint.
Methods: A quantitative cross-sec-
tional survey was conducted in Mari-
bor, Slovenia, and the surrounding 
area to collect quantitative data from 
family medicine outpatient clinics. 
Two hundred and fifty patients were 
randomly selected among those receiv-
ing either paper or electronic sick leave 
certificates. The survey was conducted 
Izvleček
Namen:   Prehod od uporabe bolniških 
listov v papirnati obliki na elektronske 
bolniške liste (eBOL) se je v Sloveniji 
zgodil z začetkom leta 2020. V svetu 
se papirnata oblika bolniškega lista še 
široko uporablja; evropske države, ki 
elektronske bolniške liste že uporabljajo, 
pa preštevajo njihove prednosti. Namen 
raziskave je bilo ugotoviti zadovoljst-
vo pacientov z novimi elektronskimi 
bolniškimi listi ter izpostaviti njihove 
najpomembnejše prednosti in slabosti 
z vidika pacientov.
Metode:   Kvantitativna presečna ra -
ziskava je bila izvedena v ambulantah 
družinske medicine v Mariboru in oko -
lici. K sodelovanju je bilo povabljenih 
250 naključno izbranih pacientov, ki so 
bolniške liste v papirnati in elektronski 
obliki že prejemali. Raziskava je bila 
izvedena preko spleta s povezavo do 
spletne ankete, sestavljene iz dveh delov. 
Ključne besede:  
zdravnik družinske medicine, 
bolniški stalež, papirnati bolniški 
list, elektronski bolniški list, 
računalniški sistem
Key words: 
family medicine physician, sick 
leave, sick leave certificate, 
electronic sick leave certificate, 
paper sick leave certificate, IT 
system
Zadovoljstvo pacientov z elektronskimi bolniškimi 
listi: raziskava v ambulantah družinske medicine
Patient Satisfaction with Electronic Sick 
Leave Certificates: Survey of Family Medicine 
Outpatient Clinics
Avtor / Author  Ksenija Tušek Bunc¹, Primož Bobek ²
Ustanova / Institute ¹Univerza v Mariboru, Medicinska fakulteta, Maribor, Slovenija; 
²Gerontološka in splošna ambulanta Polonca Vobovnik Grobelnik, Maribor, Slovenija;
¹University of Maribor, Faculty of Medicine, Maribor, Slovenia; 
²Gerontology and General Outpatient Clinic Polonca Vobovnik Grobelnik, Maribor, Slovenia;
Naslov za dopisovanje /  
Correspondence
Izr. prof. dr. Ksenija Tušek Bunc, dr. 
med.
ksenija.tusek-bunc@guest.arnes.si
+ 386 41 699 690
https:/ /doi.org/10.18690/actabiomed.266, CC BY 4.0
© 2024 Avtor(ji) / The Author(s)

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Prvi del je obsegal osem trditev o izkušnjah z elektronskimi in 
papirnatimi bolniškimi listi in petstopenjsko Likertovo lestvi -
co. Drugi del je vseboval dve vprašanji z več možnimi odgov -
ori o prednostih in slabostih eBOL. Za statistično analizo 
podatkov je bila uporabljena bivariatna statistična analiza.
Rezultati:   Od povabljenih 250 pacientov se jih je na pov -
abilo za sodelovanje v anketi odzvalo 80 (stopnja odziva 32 
%). Povprečna starost je bila 46,2±11,2 let. Sodelovalo je 56 
(70 %) oseb ženskega in 24 (30 %) moškega spola. Po več kot 
letu dni rabe je 57 (71,3 %) anketirancev izrazilo popolno 
strinjanje, da pacientom eBOL olajša urejanje bolniškega 
staleža, 55 (68,8 %) pa, da je eBOL ustrezno nadomestilo 
papirnatim bolniškim listom. Kot najpomembnejšo prednost 
eBOL je 76 (95 %) sodelujočih izpostavilo izogib dodatnim 
obiskom ambulante zaradi urejanja bolniškega staleža, kot 
največjo slabost pa negotovost glede podatkov, ki se pošiljajo 
s sistemom eBOL (64 oz. 80 % anketirancev).
Zaključek:   Rezultati raziskave so pokazali, da so bili pa -
cienti znatno zadovoljnejši z eBOL že ob uvedbi, z nadaljnjo 
uporabo pa se je njihovo zadovoljstvo še povečalo. Jasnejši in 
širši vpogled v prednosti in slabosti novo uvedenega infor-
macijskega sistema in v zadovoljstvo uporabnikov bi dobili 
s širšo raziskavo, ki bi vključevala večje število ambulant in 
bolnikov po Sloveniji, in tudi mnenja zdravnikov.
online with a web survey link and consisted of two parts. 
The first part included eight items measuring patients’ ex -
periences with electronic and paper sick leave certificates, 
rated on a five-point Likert scale. The second part consisted 
of two multiple-choice questions regarding the advantages 
and disadvantages of eBOLs. The data were analysed using 
bivariate statistical analysis.
Results: Out of the 250 patients invited to participate 
in the study, 80 responded, resulting in a response rate of 
32%. The mean age of the participants was 46.2 ± 11.2 
years, with 56 (70%) women and 24 (30%) men. After 
more than a year of usage, 57 (71.3%) respondents ex -
pressed complete agreement that the eBOL system makes it 
easier for patients to manage their sick leave. Furthermore, 
55 (68.8%) participants considered eBOLs as a good al -
ternative to paper sick leave certificates. Most participants 
(76 (95%)) considered avoiding additional outpatient visits 
to manage their sick leave as the most significant advantage 
of using eBOLs. However, 64 (80%) respondents expressed 
uncertainty about the data sent by the eBOL system as the 
most significant disadvantage.
Summary: The survey results showed that patients were 
already significantly satisfied with the eBOL system when 
it was first introduced and that their satisfaction increased 
with continued use. A broader survey including a larger 
number of Slovenian outpatient clinics and capturing both 
patients’ and doctors’ opinions would provide more precise 
and broader insights into the newly introduced IT system’s 
advantages and disadvantages and its users’ satisfaction.
INTRODUCTION 
In the 21st century, healthcare systems worldwide 
are facing new challenges due to advancements in 
technology and communication. In response to the 
accelerated evolution of medicine and the health 
ecosystem, countries are digitising their healthcare 
systems to keep up with these changes and improve 
patient care. This digitisation provides easier access to 
health data and other parts of the healthcare system, 
which helps improve patient outcomes and healthcare 
quality. That is particularly crucial in light of global 
health concerns, such as the COVID-19 pandemic 
(1, 2).
The transition from physical to digital systems in 
the healthcare sector is a lengthy process due to the 
complexity and interconnectedness of healthcare 
systems. It takes time for the general population to 
learn about and get used to the innovations offered 
by digital healthcare. Most countries have prioritised 

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the digitisation of the secondary and tertiary levels of 
healthcare along with components that are standard 
to all healthcare system levels, such as ePrescriptions. 
However, the digitisation of the primary level and 
elements specific to each healthcare system level, 
such as sick leave certificates, usually follows later 
(3). Digitisation in healthcare not only simplifies 
previously paper-based procedures, like the issuance 
of sick leave certificates but also makes them more 
secure.
A certificate of an excused absence from work 
(in general), or “sick leave certificate”, is a public 
document issued to insured persons by a family 
medicine physician or a paediatrician. The employee 
then must deliver it to their employer. The Health 
Insurance Institute of Slovenia (HIIS) and the 
Chamber of Commerce and Industry of Slovenia 
(CCIS) have identified various administrative 
barriers to using paper sick leave certificates. These 
primarily include: (i) the insured person’s time spent 
traveling to the outpatient clinic for the issuance of 
a sick leave certificate, (ii) the delivery of a paper sick 
leave certificate to an employer, (iii) the manual input 
of data by an employer into the IT system for time 
and payroll recording, and (iv) the need to attach all 
original documents when claiming reimbursement of 
salary compensation. Moreover, (v) paper sick leave 
certificates can be quickly lost or even altered, adding 
to their inconvenience (4).
Electronic sick leave certificates (eBOLs) offer a 
solution to most of the shortcomings of paper sick 
leave certificates. They are also more secure and 
reliable, thanks to the numerous checkpoints within 
the system that ensure the accuracy and integrity of 
the data and the physician’s digital signature (3). In 
Slovenia, family medicine physicians handle around 
1.5 million sick leave certificates annually, making 
the management of paper records a significant burden 
for the healthcare system. In Malta, for example, a 
study on the administrative burden of managing 
sick leave found that sick leave certificates account 
for more than 11% of medical treatments in family 
medicine outpatient clinics, which is comparable to 
the European average (3).
Interestingly, in the EU, despite the high overall 
development of its member states and the digitisation 
of its member societies, many countries still rely on 
a combined system of paper sick leave certificates 
and scanned documents sent by email. Among 
the European countries that first introduced fully 
integrated digital systems are Sweden (introduced in 
2015 with a pilot project conducted as early as 2011) 
(6), Poland (2016) (7), Latvia (2016) (8), Norway (2018) 
(9), and Russia (2017) (10).
Several studies conducted in the UK, where paper 
sick leave certificates are still used, identify similar 
issues to those found in Slovenia. They include a 
high administrative burden on family medicine 
physicians, possible duplication or loss of paper sick 
leave certificates, and extra work for insured patients 
who need to deliver paper sick certificates from their 
doctor to their employer (11). The researchers also 
noted that many family medicine physicians would 
like to receive more detailed and practical guidance 
or training on managing sick leave and transitioning 
to a more integrated electronic system (12).
In Poland, the e-system was introduced on a trial basis 
in 2016. The system significantly reduced the time 
spent managing sick leaves by more than 75%, from 
an average of 13 minutes to just 3 minutes per case. 
Related administrative issues, such as managing sick 
leaves of insured persons with multiple employers, 
also decreased. In addition, the e-system improved 
sick leave oversight and increased data security. Due 
to the trial’s success, Poland permanently introduced 
the e-system in 2018 (7).
At the beginning of 2020, after a three-month trial 
in selected outpatient clinics, a new IT solution was 
introduced in all family medicine outpatient clinics in 
Slovenia—the eBOL certificate of an excused absence 
from work. It replaced the paper form (the so-called 
“sick leave certificate”), thus relieving insured people, 
clinics, and employers from additional work. Until 1 
February 2020, both paper sick leave certificates and 
eBOLs were accepted. After this date, paper sick leave 
certificates were discontinued. However, exceptions to 
this rule exist for those employed abroad and certain 
other groups, such as farmers, self-employed persons, 
clerics, those simultaneously employed in other EU 
countries, and employees of employers who do not 
have a legal basis to join the SPOT Slovenian Business 
Point portal (e-VEM). The introduction of the eBOL 

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system is one of the most significant measures taken 
in the recent digitisation of operations within the 
state in the Republic of Slovenia.
Every insured person can access the system through 
a digital certificate on the HIIS portal for insured 
persons. They can also access it with their employer 
or at a nearby HIIS unit (13). Transitioning to a 
digital system of managing sick leaves is a complex 
process involving health care providers, insured 
persons, employers, the Financial Administration of 
the Republic of Slovenia, National Institute of Public 
Health, and HIIS (14).
This study aimed to determine patients’ satisfaction 
with the new eBOLs and highlight their most 
significant advantages and disadvantages from the 
patient’s viewpoint.
We anticipated that at least 50% of respondents would 
have a favourable perception of eBOLs upon initial 
contact and that they would be viewed as a viable 
substitute for traditional paper-based medical records. 
Moreover, we expected that individuals younger than 
50 years of age would find eBOLs more satisfactory 
than older patients. Lastly, our assumption was that 
there would be no significant statistical differences 
between genders.
PA TIENTS AND METHODS
In November 2021, a cross-sectional quantitative 
study was conducted among visitors to family 
medicine outpatient clinics in Maribor, Slovenia, 
and the surrounding area. Due to the SARS-CoV-2 
pandemic, an online questionnaire was used to 
facilitate and secure the study implementation. 
Patients were invited to participate in the study via 
a web application with a welcome address and a link 
to the online survey. Two hundred and fifty randomly 
selected patients and eBOL users were invited to 
join the study. In the Health Centre Dr. Adolf Drolc 
Maribor, all of the 59 family medicine outpatient 
clinics were included. Patients were randomly selected 
from the central register including all family medicine 
outpatient clinics. The researchers received codes of 
patients who met the inclusion criteria and performed 
random selection on this sample. In the final step, the 
health centre administration office notified selected 
patients and asked them to participate using the health 
centre-implemented web application. All family 
medicine physicians were also informed about this 
ongoing research, which may involve their patients.
The study had specific inclusion criteria that included 
individuals between the ages of 25 and 65 with a 
history of using both paper sick leave certificates and 
eBOLs. The study excluded unemployed individuals, 
pensioners, patients who had not used either eBOLs or 
paper sick leave certificates, patients not employed in 
Slovenia, patients whose employers did not have a legal 
basis for accessing the e-VEM operational support 
system, and patients who were under 25 or over 65 
years of age. The online survey questionnaire used 
in the study was anonymous, and participants were 
informed about this in advance in the introductory 
remarks. 
After reviewing the existing literature, we could 
not find a suitable validated questionnaire for our 
research purposes. Therefore, we designed a short-
form questionnaire with key items connected to the 
eBOL system, which included items similar to those 
used to evaluated other electronic health services, i.e., 
general satisfaction, utilisation, time consumption 
and safety (15). The eBOL-specific questions were 
designed by the researchers, who then consulted 
two external experts in the field of family medicine 
regarding the quality of the questionnaire. 
The questionnaire consisted of three segments. In 
the first segment, respondents were asked to provide 
their gender and age. In the second part of the survey, 
participants were asked to indicate their agreement 
or disagreement with eight items focused on eBOLs 
and traditional paper sick leave certificates. These 
items included questions about their satisfaction with 
eBOLs when they were first introduced, their current 
satisfaction with eBOLs, the usefulness of eBOLs 
for employers and their chosen family medicine 
physicians, and whether the current pandemic 
affected their opinion of sick leave certificates. Items 
were measured on a five-point Likert scale.
In the third and final part of the survey, participants 
were asked to select up to three items from a list of 
six that they believed highlighted the advantages 
and disadvantages of eBOLs. The collected data 

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were then analysed using IBM SPSS version 28 for 
Microsoft Windows (IBM Corp., Armonk, NY, USA). 
A t-test for independent samples and the Pearson 
correlation coefficient were used for the statistical 
comparison of the data by gender and age. Cronbach’s 
alpha coefficient was used to calculate the reliability 
of an eight-item instrument measuring eBOL user 
satisfaction. A value of p < 0.05 was considered to 
determine statistical significance. 
The Medical Ethics Committee of the Republic of 
Slovenia approved the study on 20 October 2021 
(approval number 0120-430/2021/3).
RESUL TS
Out of the 250 patients invited, 80 (32.0%) completed 
the survey. Of those who responded, 56 were female 
(70.0%), and 24 were male (30.0%). The majority of 
respondents (44 (55.0%)) were under 50 years of age, 
while 36 (45.0%) were over 50 years old. The youngest 
respondent was 25 years old, and the oldest was 63 
years old. The average age of all participants was 46.2 
± 11.2 years. The mean age for men was 44.6 ± 9.3 
years, and 46.9 ± 12.3 years for women. Having used 
eBOLs, 57 (71.3%) respondents expressed complete 
agreement with the view that eBOLs make it easier 
for patients to manage their sick leave, and 55 (68.8%) 
considered eBOLs as a good alternative to paper-based 
sick leave certificates (pBOLs) (Table 1).
Cronbach’s alpha coefficient of the eight-item 
instrument was 0.741, which constitutes an acceptable 
reliability level. 
The 5-point Likert scale applied to the eight-item 
instrument was considered to yield interval scale 
data; therefore, the Pearson correlation coefficient 
was used to determine associations between eBOL 
use satisfaction and age (also measured on an interval 
scale). The results presented in Table 2 show that none 
of the eight items resulted in a significant association 
with age. In the second part, we calculated the mean 
values and standard deviations of the eight items and 
compared them by gender. Similarly, the results in 
Table 2 show no statistical differences in satisfaction 
with eBOL use between male and female respondents. 
Table 1: Patients’ self-assessed satisfaction with the use of electronic sick leave certificates
Item
Satisfaction rate with eBOL
1 (%) 2 (%) 3 (%) 4 (%) 5 (%)
When I first encountered eBOL, I 
preferred pBOL*.
45 (56.3) 5 (6.3) 17 (21.3) 7 (8.8) 6 (7.5)
Currently, I would be more satisfied with 
pBOL certificate than with eBOL.
49 (61.3) 7 (8.8) 16 (20.0) 5 (6.3) 3 (3.8)
eBOL is a good alternative to pBOL. 5 (6.3) 0 (0.0) 8 (10.0) 12 (15.0) 55 (68.8)
eBOLs make doctors' work easier. 0 (0.0) 0 (0.0) 22 (27.5) 15 (18.8) 43 (53.8)
eBOLs make it easier for patients to 
manage their sick leave.
2 (2.5) 0 (0.0) 13 (16.3) 8 (10.0) 57 (71.3)
eBOLs provide better transparency of 
sick leave.
2 (2.5) 7 (8.8) 22 (27.5) 10 (12.5) 39 (48.8)
The coronavirus epidemic has positively 
impacted my opinion of eBOL.
13 (16.3) 5 (6.3) 35 (43.8) 6 (7.5) 21 (26.3)
My employer frequently faces issues with 
eBOL.
29 (36.3) 11 (13.8) 32 (40.0) 1 (1.3) 7 (8.8)
Scale: 1 – strongly disagree, 5 – strongly agree
*pBOL: paper sick leave certificate

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The majority of respondents (95.0%) highlighted 
eliminating the need to visit the outpatient clinic to 
manage sick leave certificates as the most significant 
advantage of eBOL use. However, the central 
weakness of the eBOL system was that it is unclear 
which data had been transmitted to the eBOL system, 
as reported by 80.0% of the respondents. Table 3 also 
outlines some other, less pronounced advantages and 
disadvantages of the eBOL system from the patient’s 
perspective.
DISCUSSION
This study was the first conducted in Slovenia to focus 
on eBOL, a rare subject in the existing literature. Our 
survey found that patients were satisfied with the 
switch from paper-based sick leave certificates to 
eBOLs, and that the eBOL system was well-received. 
Most respondents highlighted that avoiding additional 
visits to the clinic to manage sick leave was the most 
significant advantage of eBOLs (Table 3). At the same 
time, uncertainty about the data sent by the eBOL 
system was seen as its most critical disadvantage 
(Table 3).
There are very few studies worldwide on user 
satisfaction with eBOLs, and most of them have been 
conducted in the United Arab Emirates in the context 
of other studies examining satisfaction with the 
transition to a comprehensive electronic healthcare 
system. A survey undertaken in five primary-level 
health facilities in Saudi Arabia in 2018 found that 
the introduced electronic healthcare system with 
an embedded electronic sick leave interface enabled 
reduced waiting times, fewer falsified patient records, 
and faster patient treatment (16).
The study results verified most of our anticipated 
findings. Specifically, our research showed that most 
patients surveyed had a favourable opinion about 
the eBOL system from their first interaction with it 
Table 2: Patients’ satisfaction with the use of electronic sick leave certificates as compared to paper sick leave 
certificates by age and gender
Item
Age Gender
r (p)
male
n=24
female
n=56 t (p)
When I first encountered eBOL, I preferred pBOL*. 0.171 (0.129) 2.0±1.2 2.1±1.4 0.216 (0.830)
Currently, I would be more satisfied with pBOL 
certificate than with eBOL.
0.059 (0.605) 1.9±1.1 1.8±1.2 0.247 (0.805)
eBOL is a good alternative to pBOL. 0.080 (0.480) 4.3±1.2 4.4±1.0 0.575 (0.567)
eBOLs make doctors' work easier. -0.040 (0.723) 4.1±0.9 4.3±0.9 0.927 (0.357)
eBOLs make it easier for patients to manage their 
sick leave.
0.155 (0.169) 4.4±1.1 4.5±0.9 0.620 (0.537)
eBOLs provide better transparency of sick leave. -0.019 (0.870) 4.1±1.1 3.9±1.2 0.816 (0.417)
The coronavirus epidemic has positively impacted 
my opinion of eBOL.
0.008 (0.942) 3.3±1.3 3.2±1.4 0.162 (0.872)
My employer frequently faces issues with eBOL. 0.138 (0.223) 2.7±1.2 2.2±1.2 1.852 (0.068)
Scale: 1 – strongly disagree, 5 – strongly agree
r: Pearson correlation coefficient, t: t-test for independent samples, mean ± standard deviation, *pBOL: paper sick leave certificate

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(Table 1). This was expected since eBOLs offer clear 
advantages over paper-based certificates in terms of 
administration and logistics. Only a small proportion 
of respondents preferred paper sick leave certificates 
(Table 1), which could be attributed to a distrust of 
innovations and digital documents or an unfamiliarity 
with their use and handling. This finding is consistent 
with other studies that report patients’ concerns 
about privacy and security when using e-services 
(16). However, our results indicate that patients are 
satisfied with eBOLs after more than one year of use, 
and their current satisfaction with them is even higher 
than at the time of their initial experience (Table 1). 
Currently, only 10% of respondents prefer paper sick 
leave certificates, while most prefer eBOLs (Table 1).
There has been an increase in the number of patients 
who prefer electronic sick leave certificates over paper 
ones. This shift is evident when comparing the data 
on patients’ perceptions of their first contact with 
eBOLs (Table 1). The number of respondents with a 
neutral opinion remained the same. Almost 84% of 
patients reported being satisfied with replacing paper 
sick leave certificates, which exceeded researchers 
expectations (Table 1). This increase in satisfaction 
levels might be attributed to patients getting used to 
the novelties and learning about the benefits of eBOLs, 
alleviating their fear of the unknown and any prior 
prejudice. Most studies worldwide were performed 
to assess user satisfaction with e-services in primary 
care. Patients generally report high satisfaction with 
e-services in primary care. Studies have shown that 
patients report improved self-care, communication, 
and engagement with clinicians (17, 18). One study 
found that patients reported improved satisfaction 
with online access and services compared to standard 
provision (18, 19). Overall, patients report satisfaction 
with e-services in primary care, including improved 
self-care, communication, and engagement with 
clinicians (18, 20).
According to the respondents, eBOLs have numerous 
benefits (Table 3). The most significant advantage is 
that patients no longer need to visit an outpatient 
clinic to obtain sick leave documentation, which is 
one of the primary goals of the eBOL system. This 
was found to be both expected and desirable.
Respondents also reported faster sick leave 
Table 3: Patients’ assessments of the advantages and disadvantages of electronic sick leave certificate use
n=80 %
Advantages of eBOL
Not having to go to the clinic solely to manage sick leave 76 95.0
Quicker processing of sick leave with the employer 54 67.5
No need to wait in the clinic for a sick leave certificate after a medical check 50 62.5
Reduced paper consumption 42 52.5
eBOL cannot be lost 17 21.3
Disadvantages of eBOL
I do not know what data have been transmitted to eBOL 64 80.0
eBOL has not been sent 48 60.0
The employer could not access eBOL due to problems with computer systems 44 55.0
The eBOL was sent with incorrect data 41 51.3
The doctor terminated my sick leave without my knowledge 21 26.3
The employer needs more time to enter sick leave 1 1.3
No automatic notification of sick leave arrangement by the electronic system 1 1.3

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management at their workplaces and the avoidance 
of waiting time for sick leave at an outpatient clinic 
(Table 3), suggesting that the goal of introducing 
eBOLs to achieve administrative relief has been met. 
Lower paper consumption was rated as significant by 
more than half of the respondents; however, this was 
below our expectations in light of current efforts to 
preserve ecosystems and the threat of climate change. 
Respondents considered the least significant benefit to 
be that eBOLs cannot be lost or accidentally destroyed 
in the same way as paper sick leave certificates (Table 
3). However, 20% of respondents who saw this benefit 
are still a substantial proportion; therefore, it would 
be interesting to see how often paper sick leave 
certificates or other medical documents that are still 
in use were lost in the past.
The main issue with eBOLs was the uncertainty 
regarding the information transmitted from the eBOL 
system to the employer (Table 3). A likely reason for 
this is that the paper sick leave certificates that insured 
persons were served with always showed all of the 
relevant sick leave information quickly and clearly. 
In contrast, with eBOLs, this information bypasses 
the insured person because of the direct electronic 
transmission. Although insured persons can access 
this information through a digital certificate or their 
employer, the findings indicate that patients need to 
be better instructed on how to use the HIIS electronic 
system, which also needs further investigation and 
improvement. For example, Polish research studies 
found that the interest in accessing electronic health 
records was very high in the younger population, 
about 70% in the middle-aged population, and only 
50% in the 60+ age group (19).
Three leading weaknesses were highlighted with 
approximately equal frequency (Table 3): problems 
with unsent eBOLs, sending eBOLs with incorrect 
data, and employers’ problems with accessing the 
eBOL system. These three weaknesses were already 
expected in the eBOL design due to teething troubles 
when the new system was adopted (4) and, according 
to the survey responses, occur relatively frequently (for 
about half of the respondents; see Table 3). Therefore, 
it would be helpful to monitor and improve the timing 
of this since considering the increase in satisfaction 
with eBOLs after one year of use, we expect to see a 
decrease in the frequency of problems with their use.
A quarter of the respondents answered that family 
medicine physicians had terminated their sick leave 
and issued an eBOL without their knowledge (Table 
3). Compared to the other answers, this is a low 
proportion; however, the researchers find it a very 
high figure that may indicate poor communication 
between doctors and patients in managing sick leave 
without personal contact or represent a symptom of 
other well-known problems related to absenteeism in 
Slovenia (21), such as non-compliance with agreed-
upon deadlines for the completion of sick leave, 
unavailability of patients during sick leave, frequent 
sick leaves, and other issues.
None of the participants disagreed with the claim 
that eBOLs make work easier for physicians (Table 1), 
which may be an encouraging indicator of patients’ 
willingness to tolerate the transition to an integrated 
digital patient management system, which should 
further ease administrative work for family medicine 
physicians. There was also very little negative 
feedback on the claims that eBOLs make it easier for 
patients to regulate sick leave, allowing for improved 
transparency. According to the survey results, the 
impact of the CoV-Sars-2 pandemic on the perception 
of eBOLs was weaker than expected, with a third 
of patients reporting a more favourable opinion of 
eBOLs than before and less than a half expressing no 
change in opinion (Table 1). The researchers assumed 
that isolation and restraint measures would better 
reflect the logistical benefits of eBOLs during the 
outbreak. The reason for this may be that e-health 
already achieved high acceptance rates prior to 
the SARS-CoV-2 outbreak (15). According to the 
survey, only 10% of respondents expressed frequent 
problems with the use of eBOLs, despite more than 
half identifying this as one of their main potential 
disadvantages (Table 1). This might be attributed 
to the initial challenges employers face in adopting 
integrated electronic systems (e-VEM), which some 
have yet to acquire.
Given the higher digital literacy of younger patients, 
the researchers expected that younger patients would 
be more satisfied with the introduction of eBOLs than 

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2024; 17 (1): 36-46
older patients (19). However, the statistical analysis 
results refuted this as there were no statistically 
significant correlations (Table 2). Possible reasons 
for this could be an insufficient sample size for the 
reliability of statistical data processing, familiarity 
with electronic systems and applications that 
was above the expected familiarity among older 
respondents, or other eBOL benefits that we had not 
taken into account, such as poorer mobility or access 
to outpatient clinics among older people, which would, 
in turn, increase their satisfaction with this digital 
solution allowing them to manage their sick leave 
from home.
Regarding gender, the researchers found that both 
women and men rated their satisfaction with eBOLs 
and the transition from paper sick leave certificates 
to the new eBoL format very similarly (Table 2). 
A noteworthy limitation in the analysis was that 
significantly more women than men participated 
in the survey. This was expected given the higher 
number of female patients in family medicine 
outpatient clinics (22, 23).
This study has several limitations. One was the use 
of an online questionnaire due to the SARS-CoV-2 
pandemic, which was a significant challenge for 
the target population. Thus, the change in the data 
collection method resulted in a relatively small number 
of respondents. Statistical analyses of small samples 
are generally less reliable due to the more significant 
variability of the results, as it is more difficult 
to determine whether the results are genuinely 
representative when interpreting them. If a physical 
questionnaire had been used and administered in the 
clinic as initially planned, a higher participation rate 
would have most likely been achieved, thus increasing 
the reliability of the statistical analysis, and improving 
the sample’s representativeness.
The survey was limited to patients of family medicine 
outpatient clinics in Maribor and surrounding 
area. Due to the pandemic situation, the number of 
participants was lower than expected. Nevertheless, 
although only 32% of the invitees responded to the 
survey, the response rate was comparatively higher 
than the usual response rate for online surveys, which 
ranges from 5% to 30% (24).
To provide a more comprehensive picture of eBOL 
use satisfaction, a larger number of practices from 
different regions of Slovenia should have been 
included.
CONCLUSIONS 
The transition from the paper-based sick leave 
certificate system to the new electronic integrated 
system has been well received by patients in family 
medicine practices. Although some expected 
drawbacks and doubts existed at the time of 
implementation, the advantages of the eBOL system 
have prevailed.
Patients should be better informed about the different 
ways to access the eBOL system to address uncertainty 
around data submission, which was identified as the 
primary disadvantage in the survey.
Further research could expand and improve the 
survey’s scope to include doctors’ opinions and a 
greater number of patients, or it could focus more on 
specific age groups.
ACKNOWLEDGEMENTS
The authors thank the patients who agreed to 
participate in this study. They thank Prof. Polona 
Selič–Zupančič, PhD, for valuable guidance in 
writing this article. Acknowledgements also go to 
Alojz Tapajner, BSc, System Engineer, for statistical 
support services and Zvezdana Marija Kompara, MA, 
CTLP, for language editing.
CONFLICT OF INTEREST
The authors of this study declare that they have no 
conflicts of interest related to the research.

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FUNDING
The researchers received no funding to carry out this 
study.
ETHICAL APPROV AL
The Ethical Committee of the Republic of Slovenia 
approved this study (No: 0120-430/2021/3).
REFERENCES
1. Klemenc Ketiš Z, Rochfort A. Sustainabil-
ity for Planetary Health: A Seventh Do-
main of Quality in Primary Care. Zdr Varst. 
2022;61(4):198-200. doi:10.2478/sjph-2022-
0026.
2. Petrazzuoli F, Collins C, Van Poel E, Tatsioni 
A, Streit S, Bojaj G, Asenova R, Hoffmann K, 
Gabrani J, Klemenc-Ketis Z, Rochfort A, Adler 
L, Windak A, Nessler K, Willems S. Differences 
between Rural and Urban Practices in the Re-
sponse to the COVID-19 Pandemic: Outcomes 
from the PRICOV-19 Study in 38 Countries. Int 
J Environ Res Public Health. 2023;20(4):3674. 
doi:10.3390/ijerph20043674.
3. Agarwal R, Gao GG, DesRoches C, Jha AK. 
Research Commentary: The Digital Trans-
formation of Healthcare: Current Status and 
the Road Ahead. Information systems re-
search. 2010;21(4):796-809. Accessed March 
24th, 2024 at: http://www.jstor.org/sta-
ble/23015646 
4. Marčun T , Vodičar A,  Copot M, Krunić R, Ljubić 
B, Polutnik,M, et al. Uvedba in prevzeman-
je eBOL preko portala SPOT. ZZZS. 2020. 
Accessed March 12th, 2024 at: https://rgzc.
gzs.si/Portals/rgzc-gzs/e-BOL%20in%20
eZahtevek.pdf
5. Soler JK, Okkes IM. Sick leave certifica-
tion: an unwelcome administrative bur-
den for the family doctor? The role of 
sickness certification in Maltese family 
practice. Eur J Gen Pract. 2004;10(2):50-55. 
doi:10.3109/13814780409094232.
6. Modin G. Electronic sick leave certificates in 
Sweden. Swedish Social Insurance Agency, 
EUMASS Congress Stockholm 2014. Accessed 
April 12th, 2024 at: https://eumass.eu/
wp-content/uploads/2019/09/Modin-Elec-
tronic-sick-leave-certificates-in-Sweden.pdf
7. Szafraniec-Buryło S, Gluchowski P, Grzegorz 
Bukato G, Prusaczyk A, Żuk P. Nationwide 
implementation of the electronic sick leave 
certificates in Poland: quality improvement 
initiative towards value-based primary care 
resulting in rapid implementation in integrat-
ed care. International Journal of Integrated 
Care. 2019 (S1);A36:pp. 1-8. doi:10.5334/ijic.
s3036
8. OPSI Latvia. Sick leave e-certificate. Obser-
vatory of Public Sector Innovation, 2016. Ac-
cessed April 14th, 2024 at: https://oecd-opsi.
org/innovations/sick-leave-e-certificate/
9. Norwegian digitalization agency. Absence 
due to illness and sick-pay. Altinn [internet]. 
Accessed April 12th, 2024 at: https://www.
altinn.no/en/start-and-run-business/work-
ing-conditions/print-sickness-and-leaves-
of-absence/absence-due-to-illness-and-
sick-pay/
10. Matyukhina A. Electronic Sick Leave Certif-
icates: How It Works. Unicon Outsourcing. 
Accessed April 14th, 2024 at: https://ubpo.
ru/en/press/publications/elektronnye_bol-
nichnye_kak_rabotaet_sistema/ 
11. Fullick S, Maguire K, Hughes K: Exploring per-
ceptions and attitudes towards the extension 
of fit note certification. Ipsos MORI. 2020. Ac-
cessed April 6th, 2024 at: https://www.gov.
uk/government/publications/exploring-per-
ceptions-and-attitudes-towards-the-exten-

POROČILO O PRIMERU / CASE REPORT POROČILO O PRIMERU / CASE REPORT
46
KLINIČNA ŠTUDIJA / CLINICAL STUDY KLINIČNA ŠTUDIJA / CLINICAL STUDY
ACTA MEDICO–BIOTECHNICA
2024; 17 (1): 36-46
sion-of-fit-note-certification/exploring-per-
ceptions-and-attitudes-towards-the-exten-
sion-of-fit-note-certification
12. Coole C, Nouri F, Potgieter I, Drum-
mond A. Completion of fit notes by GPs: 
a mixed methods study. Perspect Pub-
lic Health. 2015;135(5):233-242. doi: 
10.1177/1757913915594197.
13. ZZZS. Elektronsko potrdilo o upravičeni za-
držanosti od dela, 2019. Accessed March 6th, 
2024 at: https://zavarovanec.zzzs.si/wps/
portal/portali/azos/bolniska_ods/ebol/ 
14. Portal GOV.SI. Pomembna novost za de-
lodajalce – do e-bolniškega lista le preko 
portala SPOT (eVEM). 2020. Accessed March 
6th, 2024 at http://evem.gov.si/evem/cms/
news/detailEugo.evem?srcsi_cms_news_
id=7422.
15. Zanaboni P, Fagerlund AJ. Patients’ use and 
experiences with e-consultation and oth-
er digital health services with their general 
practitioner in Norway: results from an on-
line survey. BMJ Open. 2020;10(6):e034773. 
doi: 10.1136/bmjopen-2019-034773
16. Wali RM, Alqahtani RM, Alharazi SK, Bukhari 
SA, Quqandi SM. Patient satisfaction with 
the implementation of electronic medical 
Records in the Western Region, Saudi Arabia, 
BMC Fam Pract. 2020;21(1):37. doi:10.1186/
s12875-020-1099-0.
17. Mold F, Hendy J, Lai YL, de Lusignan S. Elec-
tronic Consultation in Primary Care Be-
tween Providers and Patients: Systematic 
Review. JMIR Med Inform. 2019;7(4):e13042. 
doi:10.2196/13042.
18. Pogorzelska K, Chlabicz S. Patient Satisfac-
tion with Telemedicine during the COVID-19 
Pandemic-A Systematic Review. Int J En-
viron Res Public Health. 2022;19(10):6113. 
doi:10.3390/ijerph19106113.
19. Bujnowska-Fedak MM, Wysoczański Ł. Ac-
cess to an Electronic Health Record: A Pol-
ish National Survey. Int J Environ Res Pub-
lic Health. 2020;17(17):6165. doi: 10.3390/
ijerph17176165
20. Dhakate N, Joshi R. Classification of reviews 
of e-healthcare services to improve pa-
tient satisfaction: Insights from an emerg-
ing economy. J Bus Res. 2023;164:114015. 
doi:10.1016/j.jbusres.2023.114015. 
21. Kovačič A, Raspor A, Kolar J, Žezlina J. Ab-
senteeism in Slovenian companies. Innova-
tive Issues and Approaches in Social Scienc-
es. IIASS. 2021;14(1):18-30. doi:10.12959/
issn.1855-0541.IIASS-2021-no1-art2
22. Vedsted P, Christensen MB. Frequent at-
tenders in general practice care: a litera-
ture review with special reference to meth-
odological considerations. Public Health. 
2005;119(2):118-137. doi:10. 1016/j. puhe. 
2004.03.007
23. Baudier L, Senn N, Wild P . Cohidon C. Consul-
tation frequency and general practitioners’ 
and practices’ characteristics. BMC Primary 
Care. 2023;24:39. doi: 10.1186/s12875-023-
01996-9
24. Shih T-H, Fan X. Comparing Response Rates 
from Web and Mail Surveys: A Meta-Analysis. 
Field Methods. 2008;20(3):249-271. doi:org/1
0.1177/1525822X08317085.