The use of web-based services within primary care in the National Health Service (NHS) in England is increasing, with 33% of patients registered to use at least one web-based service in January 2021 compared with only 19% in April 2017 [1]. Although still at levels below those found in other countries such as the United States [2], the use of web-based services is likely to grow, given that it is supported by contractual mandates from NHS England [3]; it is part of wider efforts to establish digitally enabled care [4]; and because of increased pressure on health care services, technological progress, and changing public expectations [5]. The use of web-based services has accelerated across primary care in many countries during the COVID-19 pandemic as a means of enabling distanced care [6-10]. Within the NHS, services provided by all primary care practices include booking a consultation (via a practice website or through a web platform linked to a practice website), ordering repeat prescriptions, and accessing electronic health records. Additional services include secure messaging, provision of test results, having a consultation (ie, receiving a response from the practice via SMS text messages, web-based messages, phone calls, or video calls), facilitating access to external resources (eg, referring patients to websites or apps that can augment their care), and providing access to practice websites for informational purposes.

The increased use of web-based services has been shown to benefit patients, general medical practitioners (primary care physicians, known as general practitioners [GPs] in the United Kingdom), and other primary care staff through improved communication between patients and GP practices, expanded health and health care knowledge for patients, and improved access to services [11-13]. For GP practices and patients to gain the potential benefits that technological innovation can bring to primary care, patients must be able to, as well as wish to, access and use web-based services [14]. There is emerging evidence that the trend toward web-based interactions creates or exacerbates pre-existing inequalities in access to health care information and services for some patient groups who may not be able, or may not choose, to use or access web-based services [15,16].

A way of supporting the use of web-based services and countering the potential for increasing inequalities may be through digital facilitation, which we have defined as “that range of processes, procedures, and personnel which seeks to support NHS patients in their uptake and use of online services” [17]. Digital facilitation ranges from the promotion of web-based services on a practice website to active coaching in the use of web-based services and provision of training and education to practice staff in the use of services so that they can better assist patients [18]. For the purposes of this research, we have not extended the scope of digital facilitation to include the facilitation of access to digitally based therapeutic interventions.

Medically underserved and vulnerable populations are less likely than other patient groups to engage in web-based services [2,19]. The reasons for lower engagement in web-based services among medically underserved populations are complex. They include factors focusing on limited access to services (eg, poor internet connection), as well as those affecting motivations to engage (eg, lack of familiarity with the internet, lower health or computer literacy, and lack of trust in web-based information sources) [19-22]. It has been suggested that a way of reducing inequalities related to the use of web-based services in health care may be to actively support vulnerable population groups in accessing and using web-based services through digital facilitation [23]. The digital competence of health care professionals and their acceptance of web-based service provision are also important for the successful implementation of web-based patient services.

Recognizing the lack of understanding of digital facilitation and its role in supporting the use of web-based services in primary care, we conducted a systematic scoping review. We aimed to identify, characterize, and differentiate between different approaches to digital facilitation in primary care; create a typology of these approaches; establish what is known about the effectiveness, perceived advantages, and challenges of different approaches to digital facilitation; examine how they affect inequalities of access to web-based services; and explore factors enabling digital facilitation. We also sought early indications of the extent to which the COVID-19 pandemic might be associated with changing approaches to digital facilitation.

We conducted a systematic scoping review of the literature. Scoping reviews are appropriate for clarifying conceptual boundaries on topics, such as digital facilitation, where a concept is new and poorly defined in the literature [24]. The scoping review was conducted in stages (Figure 1) to allow learning from earlier stages to be fed into later stages. The protocol for the study was registered with PROSPERO (International Prospective Register of Systematic Reviews; registration number CRD42020189019) [25].

Our focus is on digital facilitation within primary care in England; however, we also consider digital facilitation in other geographical areas and other health care sectors where there is clear relevance to primary care. Primary care is distinct from other types of health care in that it is typically the patient’s first point of contact within the health system, and the primary care staff is tasked with caring for the patient as a whole rather than focusing on specific conditions [26]. Primary care is also at the center of the NHS’s Digital First plans [27] and faces particular challenges around rising demands in the face of workforce pressures [28]. Although this study focuses on primary care, some findings will also be relevant to wider health care contexts.

This review was conducted in collaboration with a study-specific patient advisory group. The group included patients and caregivers. A total of 2 web-based meetings took place over the course of the project; between meetings, group members were involved via email or on a one-on-one basis. The patient advisory group contributed to the development of the search strategy; operationalization of key terms; discussion of findings, including identified themes and gaps; data synthesis; and report drafting.

A key inclusion criterion for all the publications was that they addressed the facilitation of web-based services. Defining the inclusion criteria a priori was challenging, given that the key aim of this work was to define the scope of digital facilitation. We focused on web-based services that were accessed by patients through websites or phone apps facilitating access to care or providing resources for self-care and not on the delivery of medical therapies through web-based platforms, such as web-based mental health therapy. These services reflected those supported by primary care practices and were in line with the focus of NHS England at the time of this research [3]. We operationalized digital facilitation and web-based services as detailed in Textbox 1. Further eligibility criteria were tailored to the stage of the screening process (eg, primary care literature and nonprimary health care literature). Detailed inclusion and exclusion criteria for each stage of the screening process are presented in Table 1.

Before the full screening of the 11,853 publications from stage 1, we undertook a pilot screening exercise examining 237 (2%) publications, during which publications were jointly screened by 2 reviewers (EG and SP) and the results were discussed to ensure consistent approaches to screening. During the pilot screening, it was agreed that publications for stages 1 and 3 would be restricted to articles published from 2015 to 2020. For stage 2, which relied on snowball-type searches of reference lists, we included articles from 2010 to 2020 as the reference lists would have had few or no eligible articles if we did not expand the inclusion criteria to earlier years. Following the pilot screening, all remaining publications were screened independently by 1 of 2 reviewers (EG and SP).

Data from eligible studies were extracted independently by 2 reviewers (EG and SP) using a data-charting form developed for this study. The form was piloted to ensure that data extraction was consistent across reviewers. We extracted data relevant to digital facilitation (digital technology type, facilitation purpose, method, mode of delivery, target population, and setting) and study details (study type, outcomes, size, and setting), aiming to capture health outcomes, staff and patient or caregiver experience, impact on service use (uptake and use of digital services), cost and equity of access to health care services and information, and the nature and extent of other reported outcomes. When considering the outcomes of digital facilitation, we focused on increased uptake and use of web-based services by patients, defining these as indicators of successful facilitation.

Studies were not formally assessed for quality as this was a scoping review, with a great breadth of studies and article types being included. 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 wherever possible to assist in judging the quality of the overall evidence base for digital facilitation. Given that we did not formally assess the quality of individual studies, we did not report on study quality. Full details of data extraction are available in Multimedia Appendix 2.

Preliminary analysis of the data extracted from stage 1 was undertaken to identify gaps in the literature and to inform subsequent stages (Figure 1). Following all extractions, data analysis followed the principles of narrative descriptive synthesis [29]. Key themes were identified and captured during charting, which were then refined and expanded during the preliminary synthesis. The synthesis involved an iterative process of internal study team discussions, analyses, and writing. The typology of digital facilitation approaches was developed through this process of internal team discussion and the synthesis of evidence. Further refinement of themes, initial synthesis, and typology was undertaken through a workshop with study team members, including patient and public involvement representatives.

The PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) flow diagram (Figure 2) shows the number of publications retrieved and excluded at each stage. In stage 1, a total of 11,853 records were screened, of which 43 (0.36%) met the inclusion criteria. Later stages identified an additional 42 publications for a total of 85 full-text publications that were included. Multimedia Appendix 3 [6,21,30-105] shows a full list of the included publications and their characteristics.

Publications focused on the United States (30/85, 35%), the United Kingdom (19/85, 22%), other European countries (23/85, 27%), Australia (8/85, 9%), or Canada (1/85, 1%) or adopted an international focus (5/85, 6%). They covered digital facilitation in the primary care sector (48/85, 56%), secondary care sector (5/85, 6%), tertiary care sector (1/85, 1%), or all health care sectors (nonspecific; 31/85, 36%). The publications used various study designs, including quantitative approaches (37/85, 44%; randomized controlled trials [RCTs]: 15/85, 18%; prospective cohort: 4/85, 5%; retrospective cohort design: 1/85, 1%; retrospective observational: 1/85, 1%; longitudinal observational: 1/85, 1%; cross-sectional: 9/85, 11%; pre-post analysis: 1/85, 1%; secondary analysis of data from RCTs: 3/85, 4%), mixed methods approaches (7/85, 8%), qualitative approaches (31/85, 36%), and literature reviews (12/85, 14%). Publications focused on a variety of disease areas, with the most common being diabetes (12/85, 14%) and depression (10/85, 12%).

Although there is a wealth of literature on the potential harms of digital services, including in terms of health and digital inequalities, there is less information in the literature included in this review discussing the potential disadvantages of facilitation efforts specifically. An example in the included literature was that communication-based facilitation efforts that require high levels of emotional engagement may contribute to distress and fatigue among staff [59]. Another example is that lists of approved apps risk being biased in the considered sample of apps when the onus is on app developers to apply for inclusion in the lists [62]. Some patients have concerns about whether web-based support to encourage continued engagement with digital services would replace valued in-person contact [53]. Email reminders, although sometimes useful, can also cause patients to avoid certain web-based services so as not to receive reminders, although this depends on individual preferences around the frequency of reminders [63]. Finally, the facilitation that provides patients with tablets or computers to use digital services in waiting rooms may compromise patient confidentiality [64].

Evidence also suggests that health care staffs’ perceptions of harm from digital services, such as negative impacts on the patient-provider relationships, increased workload, and patients misinterpreting web-based health information, may negatively affect their willingness to recommend digital services to patients [65].

We found little evidence from studies examining digital facilitation for vulnerable populations, and no studies directly compared different approaches. However, few studies identified strategies that may be effective in increasing the uptake and use of digital services in specific patient populations. For example, a systematic review found that technical training and assistance programs have the best evidence for increasing portal use for vulnerable populations (older adults; racial minorities; and individuals with low socioeconomic status, low health literacy, chronic illness, or disabilities) and that other interventions do not have sufficient evidence [31]. 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 the barriers to receiving care faced by African American and Latino patients [50] and patients in low-income areas [51].

There is concern that older people will need extra support to be able to use digital services [66,71]. Some studies showed that older patients were more likely to use digital services after facilitation efforts [106]. Ongoing training and support may also be helpful in encouraging the uptake and use of digital services among older people [48]. Despite concerns about older adult groups being less able or willing to use technology [55,67], evidence suggests that they are nevertheless often willing to use tablets [80], patient portals [21], remote video consultations [73], and health-related apps [62]. Several studies pointed to the importance of ongoing human support [53] and training on both the technical aspects of digital services and general digital literacy skills for older patients [48]. Several studies included subgroup analyses, which revealed that patients with lower health literacy or disabilities were less likely than others to use digital services even after facilitation efforts [43,66,106].

There is some evidence that providers may be more willing and able to engage in digital facilitation efforts with patients who are already confident users of digital services, including the worried well, potentially exacerbating inequalities in access to digital health resources [71,83]. 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 [36,65].

We found a rich vein of information about ways in which health care staff in primary care settings can facilitate patients’ use of digital services. There is a wide range of approaches to digital facilitation. On the basis of the literature, we developed a novel typology encompassing digital facilitation aimed at patients (promotions, training and education, guidance, and support) and digital facilitation aimed at primary care staff to facilitate patients’ use of digital services.

Our review shows diversity in the types of interventions that can be considered under the umbrella term digital facilitation. Developing a common framework to define and categorize these advances the evidence base and informs the selection and implementation of different types of facilitation. It also furthers the conceptual understanding of digital facilitation, which is important for informing evaluations of facilitation approaches. Understanding which approaches work best for whom and in which contexts will be critical for enabling widespread equitable use of digital technologies in primary care, and developing an accurate typology is a necessary first step. We anticipate that future research will seek to refine our proposed typology further. From our review, possible areas for further differentiation may relate to the mode of delivery (eg, in person or on the web) and the degree to which facilitation is passive or active.

Our review found evidence that most digital facilitation efforts can support the initial uptake of digital services by patients but that they are unlikely to contribute to sustained use. For example, we found evidence that promotion efforts such as recommendation by practice staff, prescription of digital services, or email and written reminders may increase initial uptake; however, there is little evidence that they lead to sustained use. Similarly, training and education on the use of digital services, such as providing initial assistance with registering for services, also appears to encourage the initial uptake of digital services; however, evidence suggests that these efforts are insufficient to promote long-term use.

Hands-on facilitation approaches, including promotion, guidance, and support by staff, have provided some of the most consistently positive evidence of the usefulness and may be especially important for older adults. This has resource implications as guidance and support take time, and active facilitation takes more time. However, no study has yet examined the cost-effectiveness of digital facilitation. Current mandates in England incentivize the uptake of services and encourage primary care practices to promote web-based services to patients through recommended methods such as posters in physical practices, promotions on practice websites, verbal promotion by practice staff, and promotion via email [3]. However, as identified in our review, promotional approaches may increase initial uptake but seem to not contribute to the sustained use of digital services. It may be that mandates and recommended approaches to digital facilitation need to be revised to recommend approaches such as guidance and coaching, which also incentivize more sustained use. However, without adequate evaluations, including cost-effectiveness studies, it is unclear whether such a mandate is warranted.

Several factors may increase the success of digital facilitation efforts, starting with perceptions among staff and patients that the digital service in question is useful. However, with so many digital services available, it can be challenging for practices to identify appropriate and effective services [115]. Therefore, an important precursor to effective digital facilitation is supporting evaluations of available digital services to help practices and local health authorities understand their impact, affordability, sustainability, and scalability [116]. This would allow practices to prioritize the services likely to be most useful in their local context and has the potential to enhance the trust of health care staff in specific digital services because of their increased knowledge about the services, both of which were found to contribute to the success of facilitation efforts.

Given the current workload pressures on primary care physicians and staff [117-119], actions that reduce the time required to provide facilitation, such as providing guidelines to help practices determine which digital services to prioritize, could increase the success of facilitation efforts. Furthermore, such approaches could also help practices meet the broader aims of digital primary care in the NHS to improve the quality of care to patients and provide efficiency gains to practices [120]. Primary care providers need to feel that the incorporation of patient-facing digital services into their practices is a net gain in terms of workload and efficiency, including any time spent on digital facilitation; otherwise, they may resist efforts to make more services available on the web.

Our review also showed that patients may be more likely to take up and continue to use digital services endorsed or recommended by GPs or other health care staff who they trust. Understanding the value and limitations of these trust relationships is especially important for ensuring the equitable uptake of web-based services. There is substantial evidence that ethnic minority groups in the United Kingdom have lower levels of trust in health care providers and, as a result, face barriers to care [121]. Communication strategies focusing on building trust and positive relationships can help increase the effectiveness of digital facilitation efforts. When positive trust-based relationships exist between GPs and patients, our research suggests that this relationship can be effectively leveraged to help patients access digital services. However, if used in isolation, this approach may leave already disenfranchised groups further excluded from valuable health care resources.

Any implementation of digital facilitation should consider its potential risks and disadvantages, however, this review found little information in the literature specifically discussing the potential disadvantages of facilitation efforts. The available evidence suggests the potential for facilitation efforts to contribute to distress or fatigue among staff. Although this review focused specifically on facilitation efforts, it is reasonable to assume that the harms of digital services being promoted to patients through these facilitation efforts would be important to consider in terms of the risks and disadvantages of facilitation. For example, there are concerns from patients and providers that digital services may replace valued in-person contact or interfere with patient-provider relationships. Holding negative views about web-based services may decrease patients’ or providers’ willingness to engage in digital facilitation efforts. It would also be important to consider the cost-effectiveness and opportunity costs in terms of primary care staff spending time and resources on digital facilitation rather than other activities.

Given the push by the NHS for primary care practices to move services to the web [3,5] and the increase in patients’ use of web-based services [122], the lack of evidence on how best to facilitate patient access to these services represents a significant gap that should be addressed through future research. A valuable next step would be in-depth qualitative studies that refine our understanding of how digital facilitation occurs in practice, including identifying where its boundaries lie and how staff and patients engage with facilitation efforts.

Future research should also evaluate the effectiveness and cost-effectiveness of digital facilitation interventions. These studies should focus on outcomes such as the impact on service provision or service use more broadly, as well as on the impacts on patient and staff satisfaction, aspects that were absent in the literature. Future research should also consider the potential unintended impacts of digital facilitation, such as increased inequities in access. Furthermore, limited evidence is available to inform the routine use of digital facilitation in primary care. Consideration of a wider range of outcomes, including patient benefits and costs from service, staff, and patient and caregiver perspectives, will help inform decisions about digital facilitation in primary care practices. Evidence suggests that the context of the patient group, existing relationships, and trust in services can all be important considerations in the effectiveness of facilitation efforts [49,50,53,67,80,91,114]. Understanding this further in the design and evaluation of digital facilitation is important. Our focus on digital facilitation underpinning the organizational aspects of primary care service delivery rather than on exploring the facilitation of digitally delivered therapeutic interventions is a limitation we recognize and which would be a fruitful area for future research.

Only a few studies identified strategies that may be effective in increasing the uptake and use of digital services in specific patient populations. These include technical training and assistance programs for vulnerable populations and providing human support for older adults. Given the existing evidence of inequalities in access to web-based services [15,16] and the role of primary care as the first point of contact for most people [26], this is likely to need careful consideration as NHS England moves forward with its Digital First approach [27]. Evidence on targeting interventions for different groups of patients and for different types of web-based services should be prioritized.

As noted, the COVID-19 pandemic has had an impact on the uptake of digital services [123]; however, it is not clear how digital facilitation efforts have been affected. At the time of our review, no published evidence was available on the impact of COVID-19 on digital facilitation efforts. Timely research is required to more fully understand the pandemic’s impact on the provision of digital services in primary care and, crucially, how practices facilitate access, particularly to vulnerable groups and those in most need of support. It is easy to think that digital facilitation may be less important, given that the pandemic has led to a surge in the use of digital services; however, as others argue, ensuring that increases in uptake are sustained will be crucial, and in the context of disrupted and backlogged routine care, digital services are likely to become increasingly important [6].

As a scoping review, a formal quality assessment of studies was not undertaken, which limited the assessment of the strength of evidence in this review. However, this allowed us to capture the breadth of the literature on digital facilitation in primary care. We were able to describe the breadth of the types of facilitation and provide some assessments of usefulness based on diverse evidence. It is possible that in restricting the selection of publications to 2015 onward, we may have missed earlier publications of relevance; however, from our staged and iterative process in restricting the date, we do not anticipate that this was likely.

The number of drivers to increase the use of digital services in primary care is likely to increase. Digital facilitation is a useful umbrella term that we have introduced into the literature to describe a range of efforts seeking to promote the uptake and use of digital services. Our review found diverse examples of digital facilitation targeting either patients or health care staff. Evidence of its effectiveness was limited, with no evidence of cost-effectiveness. Methods of promotion or initial training appear to be effective in increasing the initial uptake of services but not sustained use without further support. Incentives or requirements for practices to increase the uptake of digital services should also include ongoing use. Despite growing concerns about inequalities in the uptake of digital services, there is limited consideration of this in the literature, either in the design or evaluation of interventions. There is a need to improve both the conceptual understanding and evaluations of digital facilitation. This study offers an initial typology that helps inform both of these key areas of consideration.