A lack of understanding and awareness about the purpose of electronic consultation systems appears particularly problematic in their implementation and impact [24]. Patient understanding and awareness was reportedly mixed, with the effectiveness of electronic consultation advertising often called into question [16,25]. Patients were often not aware of alternative methods available to them, and how to access or operate such services [16,24]. Atherton suggests this is a matter for individual practices rather than policy directives [24].

A difference in staff and patient expectations regarding the appropriate use of electronic consultations was also reported [3]. This primarily related to the inappropriate use of electronic consultations to get a timelier face-to-face appointment as later discussed.

Studies identified a low uptake as a further barrier to electronic consultation implementation [1,3,4,6,11,16,24]. Engagement levels were often reported to be much lower than expected [3]. For example, Banks et al [4] reported that only around 6% of practices used some form of electronic consultation. Similarly, Edwards et al [16] concluded that of the 36 practices reviewed, there was an average of 2 electronic consultations per 1000 patients per month. Such findings mirrored calculations by Cowie and colleagues [11]; the highest submission rate reported was almost 0.1 consultations per patient per year.

The suitability of electronic consultations for certain patient groups, conditions, and demographics was also called into question. Electronic consultations were considered more suitable for certain patient groups with discrete, “straightforward,” or familiar ongoing treatment queries [1,3,24,27]. In comparison, face-to-face consultations were reportedly preferred for new, acute, or complex cases that required physical examination and/or regular monitoring [3,4,16,24,26]. As a result, some health care professionals expressed concern that patient groups including those with long-term conditions, multimorbidity, and/or mental health problems would be disadvantaged or unintentionally excluded from electronic consultation opportunities [8,24]. Some GPs repeatedly expressed concerns that introducing a new technology could create or widen existing inequalities in access to health care [3,27,29]. Atherton acknowledged the purposeful selection of patients by health care professionals, including receptionists and administrators, based on their assumptions of who they felt would be able to use electronic consultations appropriately [24], highlighting further concerns regarding unintentional or intentional exclusion.

In regard to demographics, included articles also suggested that women are almost twice as likely to use electronic consultation systems than men [6,11,16]. Younger patients are also more likely to engage with electronic consultation systems, with levels of engagement typically declining with age [3,6,11,16,24]. Levels of education, language [3], and employment were also shown to influence electronic consultation use [6,24,27].

Following this, a range of contextual factors including practice size, deprivation, and geographical location appeared to influence electronic consultation implementation and effect [29]. Hanna et al [29] suggested that the bigger the practice size, the more support available, including a website, an information technology (IT) manager, and a triage team, thereby influencing implementation efforts and sustainability [29].

Finally, cost was reported as a significant barrier to electronic consultation engagement and implementation [3,4], with limited evidence available to justify its associated expense [4,11]. As suggested by Farr et al [3], costs often prohibited long-term engagement with electronic consultation systems.

In regard to how people work with electronic consultations (collective action), the majority of included studies reported an increase in clinician workload. This was often attributed to additional follow-up and/or face-to-face consultations due to a lack of sufficient information being provided [1,4,6,11,16,27,28]. Although one study acknowledged a potential benefit of having the clinical issue documented prior to a face-to-face appointment [4], this conclusion was contradicted by another article that found that follow-up appointments were typically longer than the national average (14.5 minutes versus 9.2 minutes for face-to-face) [16]. However, it is important to note that this disparity may be a result of a lack of GP continuity between electronic and follow-up consultations [3].

GPs also reported significant difficulties in establishing a patient’s primary concern, following an inability to probe for further information [3,4,16]. Where reported, most electronic consultations resulted in either follow-up phone calls or face-to-face appointments, leading GPs to report a duplication in their workload, as opposed to a desired reduction [1,3,6]. The relatively low uptake of electronic consultation systems as previously described appeared to exacerbate this concern [11].

An increase in administrative workload was also reported, particularly the frequent need to contact patients regarding their electronic consultation outcome or to arrange a face-to-face or telephone appointment [11]. Cowie et al [11] reported that most practices made at least three attempts to contact patients, frequently reporting that contact could not be made. The use of a withheld number was suggested as a possible explanation. Some practices have developed methods to facilitate email contact as a solution to this problem, although issues of data security and protection remained a concern [11].

Linked to concerns of data security and protection, medicolegal issues were also identified as a barrier to electronic consultation implementation and use. Concerns about the negotiation of clinical risk and diagnosis uncertainty were repeatedly expressed within the context of an increasingly litigious culture [8,27,29].

As previously mentioned, some practice staff members expressed concern regarding “patients gaming the system” [4], with some reportedly using the system to achieve a timelier face-to-face appointment [3,4,6,11]. As reported by Banks et al [4] and others, staff often felt patients could get an appointment quicker using electronic consultation methods by circumventing traditional, often telephone-based appointment systems. The responsibility of the practice to contact the patient within a specified time frame, often by the end of the next working day [4,6], as well as the content of marketing material [11], appeared to influence this perception.

Finally, the reliability of technology was seen as a potential barrier to electronic consultation implementation and use. As reported by Hanna et al [29], some interviewees felt new IT systems were highly reliable, while others expressed concern about network availability and speed [27,29]. The interoperability of IT systems was also identified as influential in electronic consultation implementation [3,11], with competing or conflicting IT systems proving to be problematic.

First, the provision of protocols, strategies, and/or guidance including medicolegal advice was considered integral to the effective implementation of electronic consultations [11,26-28]. As identified by Cowie et al [11], the development of a clear strategy for introducing electronic consultations prior to any implementation was considered fundamental. Such protocols should be developed in collaboration with staff, patients, and electronic consultation champions (as discussed below) [11].

Following this, quality patient and staff education on what electronic consultations are, what they are not, and when to use them was widely encouraged [3,6,11]. Cowie et al [11] recommended the construction of practice process diagrams along with clear objectives to facilitate staff understanding and awareness. An exploration of staff expectations was also considered integral [11].

Linked to the provision of education was a desire for more focused marketing [6,11,26]. Identified ways of promoting and marketing electronic consultations included leaflets, clear website positioning, posters, and recorded telephone messages [26]. As suggested by Ogden et al [26], recorded messages appeared particularly influential when recorded by a doctor.

Combining the development of protocols, education, and marketing, patient and public involvement was also considered integral prior to and during any electronic consultation implementation to ensure acceptability and understanding [3,11]. Despite this, few practices reported engaging with patients in electronic consultation design, implementation, or evaluation [3]. This may explain some of the issues identified regarding patient understanding and awareness. Patient participation groups (PPGs) were identified as a beneficial resource for facilitating patient engagement, as were patient and public involvement workshops to provide feedback on electronic consultation systems, protocols, and experiences [11].

Moving on to cognitive participation, how stakeholders engaged with electronic consultations, adequate staff training that addressed how electronic consultations operate, how electronic consultations fit with existing practice processes, and individual responsibilities were considered essential for successful implementation [8,11,26-28].

An electronic consultation champion was also considered helpful in ensuring effective implementation and engagement by promoting its use among patients and more reticent staff members [11,28]. However, the risk of jeopardizing staff and patient commitment by recruiting a critical champion was also acknowledged [28].

With regard to collective action (how stakeholders work with electronic consultations), strategic marketing or signposting was identified as a facilitating factor [3,6,11]. For example, signposting patients to use electronic consultations in certain situations where only remote GP access was likely to be required, including follow-up appointments, general administrative queries, repeat prescriptions, and general advice [11]. A more focused marketing strategy was considered to help improve overall efficiency, ensuring patients who might benefit from the service most were directly encouraged to engage with it [11].

In response to concerns of engaging in telephone “ping-pong,” a desire for the development of an alerting system to inform patients of an incoming call following an electronic consultation request was also expressed [6,11]. Some practices already provide an estimated time for patient call-backs, clearly informing the patient that this may be from an unavailable or unknown number [11]. The development and effective incorporation of email contact was also expressed as a desirable solution to improving electronic consultation implementation and effectiveness [11], although this is reliant on the smooth integration of electronic consultations into existing IT systems as described below [28].

Mair et al [28] suggested clinicians may be deterred or become resistant to working with a system that adds complexity or requires additional effort and time. IT support was therefore considered integral to implementation [27], as was adequate resourcing, particularly financial support [28].

Finally, the possibility of allocating electronic consultations to GPs who had had previous contact with the patient was seen as an effective way to facilitate implementation [3]. Table 2 provides a visual representation of the barriers and facilitators outlined in this review, according to the relevant domains of NPT.