Sections of this chapter have been reproduced from Leach et al.74 under licence CC-BY-4.0.75
Aims of literature review
The aims of this scoping review, conducted in autumn 2020, were to: identify, characterise and differentiate between different approaches to DF in primary care; and establish what is known about their effectiveness and cost effectiveness, perceived advantages and challenges, and how they affect inequalities of access to online services. We also sought early indications of the extent to which the COVID pandemic may be associated with changing approaches to DF. Our particular focus is on DF within general practice in England, but we also consider DF in other geographical areas and sectors where there is clear relevance to primary care.
In the following sections, we describe our review methods and document and discuss our results, including outlining a typology of DF, providing evidence on the efficacy of DF and reporting factors that enable successful DF. We highlight implications of our findings for medically underserved and vulnerable populations, and the potential role of DF in reducing inequalities in access to and use of online services for health purposes.
Methods
We conducted a systematic scoping review of the literature, as the basis for the remainder of the research. We sought to understand the current landscape of DF in primary care. Scoping reviews are appropriate for clarifying conceptual boundaries on topics, such as DF, where a concept is new and poorly defined.76 By including multiple searches, the scoping review method allows the search strategy to evolve as conceptual boundaries are clarified through screening activities. Our protocol was based on guidelines from the PROSPERO international register of systematic reviews77 and was prospectively registered with that website.78
The scoping review was conducted in stages as shown in Figure 2 to allow learning from earlier stages to feed into later stages.78 All searches were restricted to English-language publications. Details of all stages’ search strings and numbers of results by database are available in Appendix 1, Tables 20–27.
FIGURE 2 Overview of literature review process. This figure74 was originally published in the Journal of Medical Internet Research (www.jmir.org), 14 July 2022 and licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). For further details, see Publications. (Figure not reproduced here; see the original article.)
Searches
Stage 1: academic literature on digital facilitation in primary care
We searched the databases: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and the Cochrane Library (we did not search the Global Health database as specified in our PROSPERO protocol78 because we did not have access to the database except at additional cost). The search strategy focused on three concepts: (1) online services; (2) DF and (3) primary care settings. Members of the Patient Advisory Group (PAG) contributed to the development of the search strategy and operationalisation of key terms, including ‘digital facilitation’. We restricted the searches to European economic area (EEA) and Organisation for Economic Cooperation and Development (OECD) countries as likely to be most relevant to primary care practice in England. We restricted the time period for the Stage 1 search to literature published in 2015 or later (up to June 2020, when the Stage 1 searches were conducted).
Stage 2: snowball searches to identify literature on digital facilitation in health sectors outside of primary care but relevant to primary care
Stage 2 consisted of snowball-type searches whereby we screened the reference lists of articles identified during Stage 1 for non-primary care health sector studies on DF that might nevertheless have relevance for DF in primary care (see Table 1 for eligibility criteria). We first screened the reference lists of studies included for full-text extraction from Stage 1. Next, we screened the reference lists of articles that we identified during Stage 1 as not fitting the inclusion criteria due to article type restrictions (e.g. protocols or editorials) but which were otherwise relevant. We searched for snowballed literature from 2010 onwards, on the grounds that although predating 2015 it was still evidently considered of some significance in 2015 or later. We did not search for snowballed literature earlier than 2010 due to the rapid change in the extent of online services since then.
| Stage of process | Criteria | Include | Exclude |
|---|---|---|---|
| All stages | Scale and spread of intervention | All scales and geographic levels from individual site to national coverage | None |
| Country | EEA or OECD countries | Countries not in the EEA or OECD | |
| Language | English | Languages other than English | |
| Availability | Full-text availability | Title and/or abstract onlyConference proceedings with no full text article | |
| Stages 1, 3 and 4 | Year of publication | 2015–January 2020 | 2014 or earlier |
| Stage 2 | Year of publication | 2010–January 2020 | 2009 or earlier |
| Stage 1 onlyScreening of academic literature on DF in primary care | Topic relevance | Digital facilitation of online services in primary health care settings where DF was implemented in some form: Implementation as part of routine service deliveryImplementation for research purposes | Where there is no reference to facilitation being implemented by or on behalf of primary care practices. Thus, solely theoretical papers are excluded |
| Article type | Original research | Theoretical and commentary articlesTrial registrations (i.e. articles registered on ClinicalTrials.gov or the WHO ICTRP registry) | |
| Stage 2 onlyScreening of literature on DF in health sectors outside of primary care | Topic relevance | Digital facilitation of online services in non-primary care health sectors where DF was implemented in some form: As part of routine service deliveryFor research purposes | Where no reference to facilitation being implemented by or on behalf of healthcare providers. Thus, solely theoretical papers are excludedArticles that address aspects of DF already covered included articles identified in Stage 1 |
| Articles that address aspects of DF found not to be covered by articles identified in Stage 1. Key gaps include: Evaluations of DF approachesCost effectivenessEffectiveness of DF approaches for vulnerable populations | |||
| Article type | Original research | Theoretical and commentary articlesTrial registrations (i.e. articles registered on ClinicalTrials.gov or the WHO ICTRP registry) | |
| Stage 3 onlyScreening of grey literature on DF in health care, all sectors | Topic relevance | Digital facilitation of online services in health care, all sectors | Where there is no reference to facilitation being implemented by or on behalf of healthcare providers. Thus, solely theoretical papers are excludedArticles that address aspects of DF already covered by included articles identified in Stage 1 |
| Articles that address aspects of DF found not to be covered by articles identified in Stage 1. Key gaps include: Implications of the COVID pandemic for DFEvaluations of DF approachesEffectiveness of DF approaches for vulnerable populations | |||
| Article type | Grey literature (i.e. literature produced in electronic and print formats outside of commercial publishing). To include, but not limited to: Government document/reportsPolicy reportsResearch reportsWorking papers | Trial registrations (i.e. articles registered on ClinicalTrials.gov or the WHO ICTRP registry) | |
| Article type | Original research | Theoretical and commentary articlesTrial registrations (i.e. articles registered on ClinicalTrials.gov or the WHO ICTRP registry) |
Stage 3: grey literature on digital facilitation in health care
In Stage 3 we searched grey literature from January 2015 to June 2020 to identify policy reports on DF in health care. The search had two main components: targeted searches of four health policy and professional association websites [The Health Foundation, The King’s Fund, The Nuffield Trust and The Royal College of General Practitioners (RCGP)}; and a general search of the Health Management Information Consortium (HMIC) database. The targeted searches of websites used combinations of terms such as ‘online services’, ‘digital’, ‘access’ and ‘patients’, using Boolean operators where website search functions allowed. The HMIC database allowed more complex searches, so we adopted a search strategy capturing concepts related to online (e.g. online, digital, virtual, technology) and facilitation (e.g. uptake, encourage, increased use). Full details of the grey literature search strategy are given in Appendix 1 (see Table 25).
Stage 4: academic literature on digital facilitation in non-healthcare sectors
We also looked, in Stage 4, for relevant academic literature from January 2015 to June 2020 on DF in non-healthcare sectors on Google Scholar. The searches were aimed at two sectors that the study team identified as potentially relevant based on their business models, which incorporate both online and offline customer services, namely: the tourism and travel sector, and the retail banking sector. Full details of the search strategy for these non-healthcare sectors are in Appendix 1 (see Table 27).
Screening
Publications for Stages 1, 3 and 4 were restricted to English-language articles published since 2015. We initially included articles from 2010 to January 2020; however, the resulting number of included publications from Stage 1 (n = 154) exceeded the scope of the project. We therefore then restricted to publications published since 2015, with the understanding that DF and widespread use of online services in primary care are relatively recent phenomena and therefore the most relevant literature was still likely to be captured by our revised inclusion criteria. For Stage 2, where publications were identified through snowball-type searches of reference lists, we expanded the eligibility to 2010–20 so as not to omit references still evidently deemed important post 2015.
A key inclusion criterion for all publications was that they addressed facilitation of online services. We operationalised this criterion as detailed in Table 2. Further eligibility criteria were tailored to the stage of the screening process (e.g. primary care literature, non-healthcare sector literature). The detailed inclusion and exclusion criteria for each stage of the screening process are presented in Table 1.
| Concept | Inclusion | Exclusion |
|---|---|---|
| Digital facilitation | Papers including reference to what is done to help patients to access and use online services, including (but not limited to): In-person assistance with using online servicesActive methods of online assistance for accessing services (e.g. chat/help functions)Passive methods of online assistance for accessing services (e.g. FAQ/help pages)Telephone-based methods of providing assistance for accessing services (e.g. help lines)Public awareness campaigns around online services (if done by general practices)Service improvements if done explicitly to improve/increase access | Papers without information on what was done to help patients to access and use online services |
| Online services | Online services accessed through a website or app, such as Health recordsPrescription orderingAppointment bookingeConsultHealthcare information | Non-online services (e.g. telephone only)Wearable devicesDelivery of therapies onlineOnline services for GPs/physicians that do not include patients (e.g. accessing continuing medical education, online clinical decision support tools without patient input) |
Prior to full screening, we undertook a pilot exercise examining 2% of the 11,853 publications from Stage 1 (n = 237), during which publications were jointly screened by two reviewers (EG and SP). The reviewers compared and discussed their results, and amended the inclusion and exclusion criteria, raising any points of concern with the members of an internal advisory group convened to advise on the scoping review. This group comprised members of the research team who were not directly involved in the literature search and screening process, but who have expertise in literature reviews (see Acknowledgements).
Data extraction and preliminary analysis
Data from eligible studies were extracted independently by two reviewers (EG and SP) using a data-charting form developed for this study. The form was piloted to ensure data extraction was consistent across reviewers. We extracted data relevant to DF (digital technology type, facilitation purpose, method, mode of delivery, target population, setting) and study details (study type, outcomes, size, setting), aiming to capture health outcomes; staff and patient/carer experience; impact on service use, cost and equity of access to healthcare services and information; and the nature and extent of other reported outcomes. Studies were not formally assessed for quality as this was a scoping review and furthermore, the breadth of study and article types included makes the use of formal quality tools impractical. However, reviewers noted the quality of the evidence source, clarity of aims, quality and comprehensiveness of the work, and any conflicts of interest from the authors (see Appendix 1, Table 28 for details) to assist with judging the quality of the overall evidence base for DF. A list of all data fields captured in the form is available in Appendix 1 (see Table 28).
During data extraction the team met frequently to discuss emerging findings, resolve uncertainties regarding the boundaries of DF activities and clarify eligibility criteria.
Before conducting further searches (see Figure 2), we undertook preliminary analysis of the extracted Stage 1 data, including in a study team workshop (attended by EG, BL, SP and JS) to identify themes emerging and gaps in the literature that might indicate a need to expand or alter the scope of our search during later stages.
We then discussed the identified themes and gaps at a second workshop with seven members of the PAG. The PAG members suggested that a barrier to DF could be the use of locums. This was an important gap in our preliminary analysis and one that was under-represented in the Stage 1 literature. The use of locums, and high staff turnover more generally, is an important potential barrier to DF because these staff might not have the proper training or buy-in for DF programmes. The PAG members at the workshop also confirmed the legitimacy of some themes we identified in the literature, including that awareness of online services by GP practices and training for staff members may be important enablers of DF, and that data privacy or security concerns by GPs or patients might hamper DF efforts. The PAG participants highlighted that although it can be challenging for members of some vulnerable patient groups to access or use online services, for others, such as those with limited mobility, online services might improve access to health care. These discussions aided in the identification of themes in the literature and later data synthesis.
Data synthesis
Data analysis followed the principles of narrative descriptive synthesis.79 We began by identifying key themes captured during charting, which were then refined and expanded upon during preliminary synthesis. We did this through a process of study team discussions, analysis and writing. Preliminary synthesis was followed by further refinement of themes through a workshop including members of the wider study team, including a PPIE representative. The narrative synthesis further aimed to characterise and differentiate between different types of facilitation and to synthesise evidence relating to effectiveness or cost effectiveness, inequalities of access to online services, or potential advantages and challenges of different approaches.
Results
Figure 3 shows the process of the literature search through a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. In Stage 1, we screened 11,853 records of which 43 met the criteria for inclusion. Later stages identified an additional 46 publications eligible for inclusion, for a total of 89 full-text publications included in the review. These are listed in Appendix 1 (see Table 29), along with information about the types of interventions and study designs.
FIGURE 3 PRISMA flow diagram of search and screening process for scoping review, by stages. This figure74,78 was originally published in the Journal of Medical Internet Research (www.jmir.org), 14 July 2022 and licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). For further details, see Publications. (Figure not reproduced here; see the original article.)
Typology of digital facilitation
There are a wide variety of DF efforts discussed in the literature. Table 3 illustrates the typology we developed based on our findings. Although DF efforts are usually directed at patients, some are aimed at primary care staff to enable them to better support patients in using digital services. The DF efforts discussed in the literature review include those that are part of routine service delivery, and those that were introduced as part of an experimental study where facilitation was implemented for research purposes.
| Typology of DF | Definition | Examples of facilitation approaches | |
|---|---|---|---|
| Digital facilitation aimed at patients | Promotion | Broad category that captures ways of raising awareness of and knowledge about digital services, endorsements of specific digital services to patients, and methods of encouraging patients to use them. | Recommendation and prescription of digital services and other communication-centred interventions; e-mails and written reminders; video introductions to digital services. |
| Training and education | Education or training to help patients acquire technical skills to use digital services or to help patients understand what features of a digital service can be helpful to them. | Initial assistance with use of digital services. | |
| Guidance and support | Ongoing help provided by clinicians or other primary care staff to patients to use digital services. | Coaching and ongoing guidance from clinicians and other staff. | |
| Digital facilitation aimed at primary care staff | Interventions to increase staff’s knowledge of digital services so that they can better support patients in their use of the services, or to increase their trust in services. | Certified list of apps and websites (for staff to recommend to patients); practice champions (to increase buy-in); training to generate awareness of online services and how to use them. | |
Digital facilitation aimed at patients
Most efforts to facilitate uptake and continued use of online services are aimed directly at patients. Within the literature we reviewed, DF was usually delivered by primary care staff such as GPs and nurses, although other staff such as receptionists were also sometimes involved. It is important to note that the literature likely under-represents unplanned or ad hoc DF activities such as promotion of online services by receptionists. The types of facilitation aimed at patients that we identified can be grouped into three categories: (1) promotion, (2) training and (3) guidance and support.
Promotion
Promotion refers to ways of raising awareness of, and knowledge about, digital services; staff endorsing specific digital services to patients; and encouraging patients to use them. A lack of knowledge by patients of available online services is a barrier that primary care staff can help overcome.80 Promotion can be via a range of media, including online, in-person during appointments, and in less personalised forms such as placing posters or promotional material in waiting rooms. Promotion efforts for digital services also vary in terms of how active providers and other primary care staff need to be. Some DF efforts require that providers actively raise the topic of digital services during consultations or that receptionists send e-mails to patients,81 while others do not require much action by staff, for example, posters or brochures in waiting rooms.82
Examples of online promotion include practices: featuring links on their website to promote an e-consultation and self-help web service,83 sending reminders or links to online services via e-mail or SMS and using online promotional videos. Engaging patients by providing a tablet for use in the practice waiting room, rather than simply relying on verbal recommendations, has also been explored in a feasibility study as a way of motivating patients to keep using an online self-regulation programme once they return home.84
There have been various types of offline promotion within UK primary care practices, such as leaflets, posters and television screens with information about online services.83 Verbal recommendation by staff is one of the most widespread routinely used methods of DF. General practitioners were willing to recommend online services if they knew they could trust the service, or if they had been involved in its design.
Training and education
Training and education may also promote uptake and use of digital services, both by helping patients to acquire technical skills to use online services and by helping patients to understand what features of an online service can be most helpful.85 In the literature we reviewed, training was delivered online through videos,86 or offline through presentations or seminars,87 and was delivered either in one session86 or over several.87
Guidance and support
Guidance and support refers to ongoing help provided by clinicians or other primary care staff, through in-person meetings or phone calls. It can be focused on technical aspects of using digital services, similar to training, but appears to most often focus on interventions that help patients set goals, keep track of progress, improve adherence and other less technical aspects of digital services.
Practice champions88 have been used in primary care to increase the use of online services. As experts in a particular online service, they provide assistance and ongoing support to patients, with the potential to increase both initial uptake and continued use thereafter. An evaluation of 11 primary care practices in the UK concluded that practice champions could promote appropriate use by patients of a web-based consultation system, as well as encourage engagement of staff.68
Clinician support was discussed in the literature as a way to provide ongoing guidance and support to patients, for example, a US study of an app to help military veterans manage symptoms of post-traumatic stress disorder (PTSD) concluded that adding clinician support improved access and utilisation of the app.89 A study of an internet platform for cardiovascular self-management in the Netherlands, where patients had the option of contacting health coaches (e.g. practice nurses), concluded that human support was crucial to initial and sustained engagement with the platform.90 Another evaluation found that patients overwhelmingly wanted online or face-to-face technical support, such as a helpdesk.91
Digital facilitation aimed at primary care staff
For primary care staff to be able to help patients use online services, they must first be aware of what services are available, how they work, why they are useful and trustworthy, and how they can benefit specific patient groups.68 Healthcare professionals also need to be clear about their role in endorsing and facilitating online services.92 There is evidence of some GPs being opposed to the use of online services by patients.93 Efforts have been made to train primary care staff and increase their knowledge, understanding and confidence in online services.
In the UK, researchers held practice-level discussions with GPs with the aim of tackling the strong views held by some GPs against prescribing online information, albeit with limited effect.93 In Spain, an experimental study examined the effects of doctors prescribing apps that had been certified by public health authorities, on patient uptake and use of digital services. Since staff buy-in is an important enabler to DF, having a list of trusted apps can be valuable.94
Other studies show that healthcare practitioners may benefit from training to acquire the technical skills to use online services;95 or to improve their communication strategy and relationship building skills, so that patients or their families are more likely to follow advice to use digital services.96,97 Such training may be delivered through online meetings, face-to-face sessions, presentations or by sending explanatory videos to staff.98
Is digital facilitation associated with increased uptake and use of digital services?
The evidence relating to whether different DF approaches increase uptake and use of digital services is summarised in Table 4 and described below.
| Typology | Digital facilitation effort | Evidence on increasing uptake and use |
|---|---|---|
| Promotion | Recommendation or prescription of digital service to patient | Staff recommendation/endorsement of a digital service was shown to be one of the most effective ways to increase patient uptake and use in two literature reviews on the topic.52,99 Qualitative evidence from primary studies also supports staff recommendation/endorsement as an effective way to boost use of digital services.100–102 |
| Strong evidence from RCTs that prescription and referral pads for digital services are effective in increasing patient uptake,98,103 along with evidence from a review on the topic.104 | ||
| Some evidence that a list of certified apps and websites (approved by a regulating body) may help providers to prescribe apps and websites to patients.94 But a study in the UK NHS found a similar approach ineffective in encouraging the use of high-quality online services.105 | ||
| Multiple mixed-methods studies suggest that recommendation/endorsement may be more effective when staff focus on specific aspects of a digital service that will be useful to particular patients, and gradually introduce patients to digital services based on their individual needs at that time.105–109 | ||
| Communication-centred interventions | Qualitative evidence and a RCT suggest that recommendation/endorsement of digital services may be more effective when staff are trained in how to best engage patients using specific communication strategies and shared messaging around the service.83,90,96,97,107,110 | |
| Strong evidence from three RCTs that interventions that help patients form specific ‘if–then’ plans are effective in increasing continued use of digital services.111 | ||
| E-mail and written reminders | Several mixed-methods and qualitative studies have shown that written materials such as brochures, leaflets and advertisements may increase patient use of digital services, and they require little effort from providers.83,106,112 | |
| Reminders (e.g. SMS messages and push notifications) have been implemented in some areas,110,113 and feedback from patients and service users suggests they may help to increase uptake and use.90,114 | ||
| Video introductions to digital services | Mixed evidence from RCTs on whether video introductions are effective in increasing uptake of digital services. No evidence that they are effective in increasing sustained use of digital services.86,115–117 | |
| Public information campaigns | In the UK, a public information campaign and personalised invitations to patients to use an electronic health record system were found to be ineffective in encouraging enrolment.82 | |
| Training | Initial assistance with use of digital services | Mixed evidence from RCTs and quantitative studies on whether initial assistance in registering and logging into digital services is effective in increasing uptake and use.38,87,118,119 Qualitative evidence suggests patients and providers feel this type of assistance would be useful,120,121 but the weight of the evidence suggests that it is likely ineffective, and that additional continued support is needed to encourage continued use of digital services. |
| Qualitative evidence suggests that allowing patients to log into and use digital services in primary care practices (e.g. in the waiting room on tablets) may encourage patients to continue using a service outside the practice.84,122 This intervention has been implemented within studies with some success.110 | ||
| Technical training support | There is a body of literature (including strong evidence from a systematic review and a RCT) emphasising the importance of technical support to patients using digital services and wider support around digital literacy and digital health literacy in encouraging patient use of digital services,81,107,114,115,123,124 particularly for older patients, patients from ethnic and racial minority groups and patients in low-income settings. At least one RCT found that simply providing information on using the internet was not effective in increasing use of digital health services.93 | |
| Guidance and support | Coaching and ongoing guidance for patients | Mixed evidence from RCTs and non-randomised trials on whether ongoing coaching and support increases uptake and sustained use of digital services.89,125–128 The weight of evidence suggests that certain forms of ongoing support are likely effective (see below). |
| Strong evidence from three RCTs and qualitative studies suggesting that ongoing guidance focused on adherence, content of digital services and goal setting is likely more effective than ongoing guidance on technical aspects alone in increasing use of digital services.111,120 | ||
| Qualitative evidence suggests that both face-to-face and telephone support are likely important in encouraging patients to continue to use digital services.90,91,94,129,130 |
Promotion
Recommendation and prescription of digital services and other communication-centred interventions
Studies suggest that promotion may increase the initial uptake and subsequent use of digital services. We explore factors that make DF efforts successful in What makes digital facilitation successful?.
A literature review of ways to promote engagement with patient portals suggested that endorsement by healthcare staff is one of the most influential factors for patient uptake and use.52 Interviews with staff, patients and families indicate that staff recommending digital services to patients may be effective at increasing uptake of those services,100–102 especially when staff focus on specific features of a digital service that will be useful to individual patients,106,107,131 where staff are trained in how to best engage patients97 and where staff have a shared understanding of the messaging around digital services.83,110
Other promotion-based DF strategies that appear to increase patient uptake of digital services include the use of written prescription or referral pads,98,104 and having a list of certified apps and websites that have been approved by a regulating body and to which practice staff can refer patients or issue prescriptions.94,103 However, an NHS accreditation scheme in 2009 to certify online information so as to increase use of high-quality sources by patients was not very effective.105
Certain communication strategies may be particularly effective. In a randomised controlled trial (RCT) examining the use of an online depression prevention programme for adolescents, intervention sites that were assessed as more completely implementing communication and relationship building techniques to help develop and maintain trust, authenticity and sincerity with adolescent patients were more effective in encouraging enrolment.96 The literature also points to the effectiveness of gradually introducing patients to digital services and to new features rather than explaining all functions at one time.108,109 Interviewing and conversational techniques such as motivational interviewing,90 and discussing patients’ ideas, concerns and expectations to help address patients’ misconceptions,107 have been shown to increase uptake of digital services. Helping patients form specific plans around the use of digital services was shown to be one of the strongest predictors of adherence in a RCT of an internet-based intervention for depression.111
E-mails and written reminders
Written material that healthcare staff can give to patients about digital services may also be useful in encouraging uptake, with minimal staff time and effort.106,112 In a study in the UK where an e-consultation and self-help web service were promoted through posters, leaflets and advertisements on television screens in waiting rooms and on practice websites, 79% of those who used the web service reported that they found out about the service through these promotion efforts.83 Reminders for participants can also be helpful,90,114 for example, through SMS messages sent by receptionists with links to online tools,110 or sent to patients at key times, such as when healthcare staff upload new notes to patient portals, which in one quasi-experimental study resulted in over 85% of patients viewing at least one note on the patient portal.113 However, a RCT of an internet-based therapy programme for depressive symptoms among high school students found that neither tailored nor standardised e-mails increased adherence.132
Training and education
Initial assistance with and education on use of digital services
The evidence is mixed about whether initial assistance with, and education on, the use of digital services are effective in increasing uptake and continued use, and the weight of evidence from quantitative studies suggests that more support to patients is likely to be needed after initial introduction sessions to promote long-term use of digital services.
For example, a quantitative study of uptake and use of patient portals for patients with chronic kidney disease found that patients of renal clinics who were helped with initial login and registration to the portal were 20% more likely to be continued users of the portal after 3 years than in other clinics.38 But there is contradicting evidence from a study on use of patient portals indicating that initial training/introductory educational sessions have little impact on actual use after initial sign-up.119
A RCT of an initial 10-minute standardised personal information session on internet-based depression interventions found that these sessions were ineffective in increasing adherence in an inpatient and outpatient rehabilitation setting for diabetes care.118 Similarly, a RCT from the Netherlands showed that initial group education sessions for patients with type 2 diabetes to help them use online platforms did not increase use of the service.87
An interview-based study suggests that letting patients use tablet devices or computers in practice waiting rooms may encourage later use at home.84 Both healthcare staff and patients expressed enthusiasm about the potential to access health information122 and complete digital screening tests110 on tablets while waiting for appointments. Other studies of initial educational sessions for patients where staff help patients sign up, install apps, provide pamphlets and answer questions on how to use online services have found that these may increase uptake and use of patient portals.38,120,121
Video introductions to digital services
Four RCTs evaluated the effectiveness of video introductions on patient uptake and use of digital services. Two studies found that online video-based trainings increased patient uptake compared with people who received no form of training or introduction,115 although sustained use after 6 months was still very low in one of the studies.116 The two remaining RCTs found contradictory results. One RCT found that a 3-minute video did not increase uptake or use of an online intervention for chronic pain,117 but another RCT found that a 7-minute video was effective in increasing acceptance of internet-based interventions for depression, although actual use was not measured.86
Guidance and support
Coaching and ongoing guidance from clinicians and other staff
There is some evidence that ongoing support from clinicians and other staff is effective in increasing the use of digital services. Although some quantitative studies found that these interventions were ineffective, the weight of the evidence suggests that certain forms of ongoing support are effective.
Several RCTs evaluated the effectiveness of having clinicians or other staff guide patients in the use of digital services as compared to self-directed services. One study found that patients using online therapy for chronic pain who were guided by a psychologist completed more modules than unguided groups and had lower attrition rates.125 But two other RCTs showed either mixed126 or no evidence127 for the effectiveness of guides and coaches to increase patient uptake and use of digital services. A series of RCTs in Germany133 found that both content-focused (personalised written feedback, reminders) and adherence-focused guidance (reminders, and ability to request feedback) were equally effective in increasing adherence as compared to administrative guidance (technical support).133
Several quantitative studies with non-randomised control groups also tested the effectiveness of coaching sessions to help patients engage with app content. Interventions such as sessions with health coaches,89 hands-on and telephone assistance from nurses, and an intensive course for patients,128 may increase uptake and use of digital services.
Qualitative evidence also suggests that face-to-face support for patients along with ongoing web support may facilitate the uptake and use of digital services.91,94,129,130 For example, incorporating digital services into regular care and providing patients with a way to message providers for support may encourage sustained engagement.90 In addition, ongoing training in the use of particular digital services or more generally to increase digital literacy skills may encourage uptake and use.91,107,114 However, a quasi-randomised control trial in the UK found that providing patients with general information about using the internet for health purposes did not increase patients’ readiness to use electronic health services.93
Evidence relating to inequality between different population groups
A few studies identified strategies that may be effective at increasing uptake and use of digital services in specific patient populations. A systematic review found that technical training and assistance programmes have the best evidence for increasing portal use for vulnerable populations (elderly people; racial minorities; individuals with low socioeconomic status, low health literacy, chronic illness or disabilities), and that other interventions lack sufficient evidence.81 A US study found qualitative evidence that ongoing training, both in the use of a particular service and more generally to increase digital and health literacy skills, can help address barriers to receiving care faced by African American and Latino patients134 and patients in low-income areas.124
Ongoing training and support may also be helpful in encouraging uptake and use of digital services amongst older people.114 Despite concerns about older groups being less able or willing to use technology,92,101 evidence suggests they are often willing to use tablets,122 patient portals,52 remote video consultations108 and health-related apps.135 Some studies showed that older patients were more likely to use digital services after facilitation efforts115 or point to the importance for older patients of ongoing human support90 and training on both technical aspects of digital services and on general digital literacy skills.114 Several studies include subgroup analyses, which revealed that patients with lower health literacy136 or with disabilities are less likely than others to use digital services even after facilitation efforts.87,99,115
Cost effectiveness
No studies in the literature we found assessed the costs of DF efforts.
Evidence of disadvantages and risks from digital facilitation efforts
The literature identifies some disadvantages and risks associated with DF efforts. For example, communication-based facilitation efforts that require high levels of emotional engagement may contribute to distress and fatigue among staff.96 Approved app lists may risk being biased in the sample of apps considered when the onus is on app developers to apply to be included on approved lists.135 Reference is also made to some patients worrying whether the ongoing engagement to get involved with digital services meant they would replace valued in-person contact.90 E-mail reminders can irritate some patients to the extent that they avoid certain online services.130 Lastly, facilitation efforts that involved providing patients with tablets or computers to use digital services in waiting rooms may compromise patient confidentiality.110
Evidence also suggests that healthcare staff’s perceptions of harms from digital services, such as negative impacts on the patient–provider relationship, increased workload and patients misinterpreting online health information, may negatively affect their willingness to recommend digital services to patients.106
There is some evidence that providers may be more willing and able to engage in DF efforts with patients who are already confident users of digital services, including the ‘worried well’, potentially exacerbating inequalities in access to digital health resources.105,137 A review found that providers are more likely to recommend digital services to patients they perceive as more technologically knowledgeable, and these perceptions may be based on age, socioeconomic status, education level and ethnic group.106,116,138
Non-health literature in the area of banking focuses on digital exclusion, with concerns that financial institutions will market digital services more among high-income groups that are already more likely to use online banking. This literature points to the role of regulators in protecting vulnerable populations which may otherwise be digitally excluded. For example, regulators may enact inclusion objectives and they may address security concerns that deter people from participating in digital finance.139
What makes digital facilitation successful?
The success of DF is influenced by the following factors.
Perceptions of usefulness of the digital service
One of the most important factors in the success of DF efforts is the perception, both from the patients and the healthcare staff, that the digital service will be useful.85,92,94,95,109,140 Qualitative evidence suggests that healthcare staff’s likelihood of recommending a digital service to patients may be influenced by the alignment of information within apps and websites with the health information and recommendations that doctors commonly provide to patients,85 and by the existence of rigorous evaluations of digital services that demonstrate patient benefit.80,107 Patients are more likely to use services that have been recommended by healthcare staff if they see the information and functionality as novel,82 if they are able to customise the service to their own needs and preferences,52,130 and if the service is specific enough to fit their needs.141
Time and capacity in primary care
Challenges in terms of staff having enough time to implement DF efforts were commonly identified in the literature.80,84,94,96,100,108,110,129,131,142,143 However, the literature also indicated ways to help address this issue. E-mail templates, protocols and scripts can help staff to automate some aspects of patient engagement.104 Passive facilitation efforts such as posters and brochures can also help to mitigate time pressures in primary care.112 In some studies, it was found helpful to have non-GPs engage with patients in DF efforts, due to time constraints for physicians,110,112,120,131 or to use the time that patients spend in waiting rooms as an opportunity to facilitate access to online services.84,110,122 One study suggested that facilitation efforts may be more feasible during certain kinds of appointments where patients may have less pressing concerns (e.g. vaccination, contraception, nutritional and physical activity-focused appointments).84
Staff buy-in
Staff buy-in and motivation were important enablers of successful facilitation efforts in many of the studies we found,38,96,135,144–146 and negative staff attitudes or a lack of motivation towards an intervention were often barriers to facilitation efforts.93,94,97,143 In several studies, buy-in was encouraged through: early engagement of staff when developing an intervention, initial education or training sessions in practices to introduce staff to new online services or interventions, ongoing communication with staff and incorporation of digital services into discussions at staff meetings.68,80,97,100,120 Early engagement of GPs and other primary care staff may also help by addressing anticipated barriers early in the implementation process.68,80,84,147 Ongoing education and training for healthcare staff in how to use digital services has also been indicated as important in helping them to engage in DF.104,106,107,148 Practice champions, that is, designated staff responsible for promoting digital interventions among other staff and patients, could also help.68,112,120,143
Re-shaping roles may also be important in securing staff buy-in.99,108,149 This not only applies to GPs and nurses, but also to wider primary care support teams. Seeing DF as part of their role rather than something added onto their existing job was important in increasing buy-in among practice receptionists.110
Trust in, and knowledge of, digital services
Qualitative studies have shown that patients’ lack of trust in online services can be a barrier to using them,122,134,150 and this is an issue reported by older patients in particular.151 Concerns about security and loss of confidentiality may also impact staff willingness to recommend digital services to patients.106,134 Efforts to increase the perceived security of websites were described in the literature, such as the use of third-party seals on patient portal websites.134
Trust in websites was also much discussed in the non-health literature we found, particularly that which looked at how to encourage people to buy travel and tourism services online. Perceived risk and trust were positively influenced by providing an explanation of security measures (e.g. non-disclosure of credit card details, encryption technology) and how information will be used, and by having a well-designed website.152 The use of third-party seals which assure consumers that a website follows particular operating procedures and/or privacy standards, along with time stamps to indicate that information is up to date, have been found to encourage trust in online vendors in the travel industry.153
Healthcare staff may be less likely to engage in facilitation efforts when they are uncertain which services are most trustworthy.80,104,142 A review suggests that frameworks that help providers to identify high-quality apps, categorise them based on topics and intervention strategies, and match them to individual patient preferences, needs and motivations, may assist healthcare staff in recommending services to patients.154
Guidelines for recommending digital services to patients and the role of regulators
Guidelines that help providers to recommend digital services to patients may also be helpful.108,145 Evidence from qualitative studies highlights the importance of simple recruitment criteria, referral guides and specific triggers that prompt the recommendation of digital services to patients.68,97,104,117,131 In some cases, mandates to recommend services have also been helpful.148 In the UK, it has been suggested that setting targets for GPs to encourage the use of digital services could potentially be effective.99 Policy that makes funding available for training, organisational development and infrastructure, and technology that allows providers to facilitate the use and uptake of digital services, will also be important in increasing use among patients.99,108,135,145,149
A review of digital first consultations in England identified a concern among clinicians of ‘medical-legal’ issues around digital services, for instance through litigation and claims of medical negligence due to the inappropriate recommendation and use of digital services.108 Guidelines and regulation may help address such issues.
Trust in healthcare staff
Trust, perhaps promoted by long-term relationships with healthcare staff, may be important in patients’ use of digital services that are recommended by those staff.101,155 Where providers have given ongoing support to patients in using a digital service, trusting relationships and a positive, personal tone may boost patients’ motivation to participate in digital interventions.90
Box 3 describes how PPIE influenced WP1.
Discussion
Our scoping review has revealed much information about ways in which healthcare staff in primary care settings can facilitate patients’ use of digital services. The range of approaches to DF is wide: to help thinking about them we have developed the typology shown in Table 3. Overall, we found that promotion of digital services through recommendation by practice staff, prescription of digital services, or e-mail and written reminders may be effective in increasing initial uptake of services. But few promotional efforts appear to contribute to sustaining use of digital services after initial sign-up, except for some communication-centred interventions that focus on helping patients to form specific plans to use digital services. Training and education on use of a digital service, such as providing initial assistance with registering for it, also appears to encourage initial uptake of digital services. But evidence suggests that patients likely require additional support beyond the initial introductory training or education session to promote long-term use of digital services. Hands-on facilitation approaches, in the form of promotion, guidance and support by staff, have some of the most consistently positive evidence of effectiveness, and may be especially important for elderly people.
Deviations from the original proposal
There were no deviations from the original proposal.
Strengths and limitations of the current literature review
We conducted a scoping review. This was appropriate given the exploratory nature of the study and our aim to capture the breadth of DF in primary care. We employed an iterative approach to identify literature relevant to DF in primary health care, including literature about health care more widely and, indeed, about non-healthcare sectors where that may have useful implications for DF in primary health care. Our focus was on the DF discussed, rather than on the quality of the study. Our approach was strengthened by PPIE inputs.
The limitations of our approach are evident from the inclusion and exclusion criteria presented earlier. In addition, by limiting the review mostly to articles published since 2015 we may have omitted earlier documents of interest. However, given the acceleration in recent years of the availability of online services for patients, we expect to have captured the large majority of relevant literature. The last few months of our literature review period overlapped with the first few months of the global COVID pandemic, but due to publication lags, we found very little literature that reflected the impact of the pandemic on the use of online services.
Gaps in the evidence base
We identified a number of areas that were not well addressed. We found few formal evaluations of DF effectiveness. While some studies examined the effects of particular DF efforts, most did not evaluate the benefits or costs of existing facilitation efforts; rather, their main focus was on ways of overcoming barriers to the uptake and/or sustained use of online services.
There were nevertheless a few formal evaluations of DF in the literature we reviewed, including some RCTs. Due to short time horizons, these studies concentrated on initial access to a service, such as registering with an online portal. There is little evidence available on how DF affects ongoing use of services, such as estimating how many more patients would routinely book their GP appointments online.
We found little comparative evidence on which types of facilitation are most effective, in what context, or for whom. Evidence of the effectiveness of DF in routine use in primary care settings is also thin, since most of the articles in our review reported on DF efforts introduced as part of research studies.
A key aim of the scoping review was to identify evidence about which, if any, models of DF are effective at reducing inequalities in the use of online services. But we found little evidence regarding the impact of DF with vulnerable groups. Just one article directly addressed the topic and a handful of other studies discussed differences in outcomes between population subgroups. Given the potential for online services to increase inequalities in access to health resources, this represents an important weakness the evidence base.
We found no studies that evaluated the cost effectiveness of a DF method, or even that quantified the costs. Some articles described time constraints in GP practices as a barrier to undertaking DF, which is presumably related to costs as well as workforce demands. However, a clearer understanding of the costs associated with different facilitation approaches, along with their effectiveness, would be important for assisting primary care practices in decision-making around implementing DF approaches.
Finally, evidence on the impact of COVID on DF is still emerging. Understanding the pandemic’s impact on the provision of digital services in primary care and how practices facilitate access to those services is a current challenge.
Suggestions for future research
Based on what we did not find, there is scope for more, and more formal, evaluations of approaches to DF. The emphasis in these evaluations could usefully be on the comparative effectiveness of different approaches, and with particular attention to the ability to sustain patients’ use of online services beyond initial sign-up. Given the push by the NHS for primary care practices to move services online,156,157 the lack of evidence about how best to facilitate patient access to these services is a significant gap to fill through future research.
The absence of economic evaluations of DF approaches is striking. There is a clear need for assessment of the costs of facilitation and the impact on the costs borne by health services, practices and patients as a result. Assessments of the cost effectiveness of DF and of different approaches in comparison with one another are much needed, to guide the use of scarce primary care resources.
Finally, although the literature we reviewed contains some examples of consideration of the differential effects of examples of DF on various subgroups of the population, the evidence overall about impact on (in-)equality of access to health care, particularly for vulnerable groups, is weak. It falls well short of providing clear guidance on how to avoid worsening inequalities, let alone reduce them, by means of DF. Starting to rectify that lack of guiding evidence is an important priority for future research.