TY  - JOUR
AU  - Darley, Sarah
AU  - Coulson, Tessa
AU  - Peek, Niels
AU  - Moschogianis, Susan
AU  - van der Veer, Sabine N
AU  - Wong, David C
AU  - Brown, Benjamin C
PY  - 2022
DA  - 2022/10/24
TI  - Understanding How the Design and Implementation of Online Consultations Affect Primary Care Quality: Systematic Review of Evidence With Recommendations for Designers, Providers, and Researchers
JO  - J Med Internet Res
SP  - e37436
VL  - 24
IS  - 10
KW  - general practice
KW  - systematic review
KW  - remote consultation
KW  - OC
KW  - triage
KW  - primary health care
KW  - care provider
KW  - health care professional
KW  - workforce
KW  - telemedicine
KW  - COVID-19
KW  - pandemic
KW  - primary care
KW  - health outcome
KW  - patient care
AB  - Background: Online consultations (OCs) allow patients to contact their care providers on the web. Worldwide, OCs have been rolled out in primary care rapidly owing to policy initiatives and COVID-19. There is a lack of evidence regarding how OC design and implementation influence care quality. Objective: We aimed to synthesize research on the impacts of OCs on primary care quality, and how these are influenced by system design and implementation. Methods: We searched databases from January 2010 to February 2022. We included quantitative and qualitative studies of real-world OC use in primary care. Quantitative data were transformed into qualitative themes. We used thematic synthesis informed by the Institute of Medicine domains of health care quality, and framework analysis informed by the nonadoption, abandonment, scale-up, spread, and sustainability framework. Strength of evidence was judged using the GRADE-CERQual approach. Results: We synthesized 63 studies from 9 countries covering 31 OC systems, 14 (22%) of which used artificial intelligence; 41% (26/63) of studies were published from 2020 onward, and 17% (11/63) were published after the COVID-19 pandemic. There was no quantitative evidence for negative impacts of OCs on patient safety, and qualitative studies suggested varied perceptions of their safety. Some participants believed OCs improved safety, particularly when patients could describe their queries using free text. Staff workload decreased when sufficient resources were allocated to implement OCs and patients used them for simple problems or could describe their queries using free text. Staff workload increased when OCs were not integrated with other software or organizational workflows and patients used them for complex queries. OC systems that required patients to describe their queries using multiple-choice questionnaires increased workload for patients and staff. Health costs decreased when patients used OCs for simple queries and increased when patients used them for complex queries. Patients using OCs were more likely to be female, younger, and native speakers, with higher socioeconomic status. OCs increased primary care access for patients with mental health conditions, verbal communication difficulties, and barriers to attending in-person appointments. Access also increased by providing a timely response to patients’ queries. Patient satisfaction increased when using OCs owing to better primary care access, although it decreased when using multiple-choice questionnaire formats. Conclusions: This is the first theoretically informed synthesis of research on OCs in primary care and includes studies conducted during the COVID-19 pandemic. It contributes new knowledge that, in addition to having positive impacts on care quality such as increased access, OCs also have negative impacts such as increased workload. Negative impacts can be mitigated through appropriate OC system design (eg, free text format), incorporation of advanced technologies (eg, artificial intelligence), and integration into technical infrastructure (eg, software) and organizational workflows (eg, timely responses). Trial Registration: PROSPERO CRD42020191802; https://tinyurl.com/2p84ezjy 
SN  - 1438-8871
UR  - https://www.jmir.org/2022/10/e37436
UR  - https://doi.org/10.2196/37436
UR  - http://www.ncbi.nlm.nih.gov/pubmed/36279172
DO  - 10.2196/37436
ID  - info:doi/10.2196/37436
ER  -