Barriers and facilitators to utilizing digital health technologies by healthcare professionals

Digital technologies change the healthcare environment, with several studies suggesting barriers and facilitators to using digital interventions by healthcare professionals (HPs). We consolidated the evidence from existing systematic reviews mentioning barriers and facilitators for the use of digital health technologies by HP. Electronic searches were performed in five databases (Cochrane Database of Systematic Reviews, Embase®, Epistemonikos, MEDLINE®, and Scopus) from inception to March 2023. We included reviews that reported barriers or facilitators factors to use technology solutions among HP. We performed data abstraction, methodological assessment, and certainty of the evidence appraisal by at least two authors. Overall, we included 108 reviews involving physicians, pharmacists, and nurses were included. High-quality evidence suggested that infrastructure and technical barriers (Relative Frequency Occurrence [RFO] 6.4% [95% CI 2.9–14.1]), psychological and personal issues (RFO 5.3% [95% CI 2.2–12.7]), and concerns of increasing working hours or workload (RFO 3.9% [95% CI 1.5–10.1]) were common concerns reported by HPs. Likewise, high-quality evidence supports that training/educational programs, multisector incentives, and the perception of technology effectiveness facilitate the adoption of digital technologies by HPs (RFO 3.8% [95% CI 1.8–7.9]). Our findings showed that infrastructure and technical issues, psychological barriers, and workload-related concerns are relevant barriers to comprehensively and holistically adopting digital health technologies by HPs. Conversely, deploying training, evaluating HP’s perception of usefulness and willingness to use, and multi-stakeholders incentives are vital enablers to enhance the HP adoption of digital interventions.


INTRODUCTION
Recent developments in health technology have positively affected multiple and essential sectors of the economy, especially the healthcare sector, by providing solutions that guarantee the exchange of medical knowledge and information and establish long-lasting health outcomes 1,2 .Digital health technologies, such as wearables devices, computerized decision support systems, and telemedicine improve the technical performance and satisfaction of healthcare employees, demonstrate potential to decrease direct and indirect costs of medical services, and enhance the quality of delivered care 3 .Worldwide, using digital solutions in practice seems inevitable, with modality-specific prevalence (e.g., 50.8% for telemedicine, 89.9% for electronic health records, and 91.9% for social media platforms) [4][5][6] .However, the prevalence of use might be even higher, as no previous study has collated and assessed the overall prevalence of using digital health technologies by healthcare providers.Likewise, several studies have suggested that ethnicity, race, geographic location, age, and medical specialty directly interfere in the adoption of technology use, evidencing the importance of understanding variables accounting for the digital divide and disparity of access [7][8][9] .
Several barriers to healthcare's overall quality, transparency, and efficiency naturally arise during or following the creation, implementation, and maintenance of digital health technologies.Therefore, during the design of any health-related project, it is essential to identify and quanti-qualitatively analyze its risks and facilitators, enhancing the likelihood of obtaining favorable outcomes and optimizing the chances of success.The efficient implementation of digital technologies, characterized by proper implementation of a systematic management approach, including strategic planning, resource allocation, and control and evaluation processes, is fundamental to refining healthcare services, equipment, and technologies [10][11][12] .In reaction to these aforementioned elements, multiple efforts have strengthened healthcare systems through employing DHTs for healthcare professionals and stakeholders from low-, middle-, and high-income countries.For instance, the World Health Organization (WHO) endorsed in the 73rd World Health Assembly the institution of the Global Strategy on Digital Health 2020-2025, in which four guiding principles rely on the acknowledgment that the institutionalization of digital health in a national system requires a decision and commitment by countries, recognition that successful digital technologies require an integrated strategy, promotion of the appropriate use of digital interventions for health, and recognition of the urgent need to address the major impediments faced by least-developed countries implementing digital health technologies 13 .Furthermore, the Regional Digital Health Action Plan for the WHO European Region 2023-2030 has a critical regional focus area on strengthening digital literacy skills and capacity-building in the general population, with particular attention to the health workforce, for the use of digital health services and disease prevention and management 14 .Due to these global actions, numerous studies have focused on assessing barriers to and facilitators for many technologies [15][16][17] .
To date, hundreds of clinical trials based on specific technologies applied to the healthcare professionals' environments have assessed the implementation of digital interventions in the healthcare system, while several systematic reviews have combined these publications, evidencing their effectiveness, safety, and feasibility.However, a summary of enablers and restraints to healthcare professionals' coordinated and integrated use of digital health technologies has not been published yet, making the current evidence dispersed, misused, and overlooked.Therefore, in this overview of systematic reviews and semantic-based occurrence meta-analysis, we report all published evidence from existing systematic reviews covering and mentioning barriers and facilitators to the solid use of digital health technologies by healthcare providers.

Study selection and characteristics
Our database and PROSPERO search are shown in Fig. 1.Our January 21, 2022 search retrieved 9,912 records, of which 139 underwent full-text review (Fig. 1, section A).Based on the inclusion and exclusion criteria, 47 studies and seven ongoing studies were included.On March 1, 2023, 2,717 new publications were identified through an additional database search (Fig. 1, section B).Of those, 142 studies were shortlisted for full-text assessment, and 60 reviews were added to our umbrella review.Two additional ongoing studies or protocols were identified.In total, this overview of systematic reviews included 108 primary systematic reviews and nine ongoing studies (Fig. 1, section C).  One sdy was identified from alternative resources. 64Fig. 1 PRISMA flow chart diagram.Reason 1-wrong intervention or platform was unclear.Reason 2-the study did not provide any relevant outcome influencing healthcare providers.Reason 3-targeted population was not healthcare providers.Reason 4-study design used did not match our inclusion criteria."healthcare professionals," "technology," "review," "barrier," "care," "systematic review," "factor," "patient," and "implementation".

Barriers and facilitators identified in included reviews and potential recommendations
The final domains created based on the thematic analysis can be accessed in Figs. 3, 4, and the summary of findings of the top seven barriers and facilitators can be accessed in As represented in Figs. 3, 4, several semantic clusters were described throughout included reviews.Herein, we outline and exemplify the five most common barriers and facilitators to the design, implementation, longitudinal maintenance, and evaluation of digital health technologies by healthcare professionals.The remaining barriers and facilitators are explained in detail in Supplementary Information 2 (pp 8).Infrastructure and technical barriers were the most frequently described barriers among included reviews, relating to issues with a limited or insufficient network, lack of existing technologies, lack of devices, compatibility with daily workflow, connectivity speed, healthcare capacity of technology integration, interconnectedness, absence of standardized/harmonized systems at different facilities, limited access to electricity, and requirement of a functional database system or large disk space.Notably, technical issues seem to be the worst in rural and countryside regions.Firstly, counteracting connectivity-related barriers involves ensuring availability (especially in rural areas) and affordability, guaranteeing high-speed fiber connectivity, and increasing the number of reliable local networks.In addition, we found reviews suggesting that to overcome infrastructure and technical barriers, the involvement of healthcare professionals in developing and implementing any health technology tools is fundamental, enhancing their capacity to manage such applications and increase their independence from co-workers and support centers.Remarkably, all reviews stated that user engagement and collaboration with system developers or associated stakeholders is crucial in all design and development stages, deployment, and continued utilization, as created applications are fit for purpose, based on understanding and addressing healthcare providers' needs and expectations.
Personal and psychological barriers involved complex thematic components, including the healthcare professionals' resistance to change, difficulty understanding the technology, perception of less human interaction, technophobia, ages, education levels, professional experience, low literacy, poor writing skills, linguistic features, adherence behavior, and fear of using particular health technology.Moreover, unwillingness, low expectations, skepticism from healthcare providers, and low motivation for compliance were also associated with personal barriers.For counterbalancing these barriers, healthcare professionals' perception of usefulness and willingness was a highly cited facilitator, characterized by the degree to which the employees believe that using specific digital health technologies would enhance their performance and the proportion of participants intending to utilize that technology.Furthermore, personal and psychological barriers could be addressed by using and adopting training programs and educational activities appropriately tailored to healthcare professionals' needs and coverage of deficient abilities.High-quality, real-time technical support and coaching also appeared as a component that increased healthcare providers' efficiency, decreased implementation fear, and potentially could reduce internal conflicts during system adoption.Importantly, training programs may be developed with the ongoing involvement of the intended community to understand their needs and knowledge gaps.Moreover, evidence shows that user-friendly design, intuitive system navigation, and easy-to-use interfaces are critical to improving overall product performance and facilitating data collection and input, data processing, and further analysis.Some reviews suggested that the limiting factors for the broad use of digital health technologies are associated with healthcare  workers' concerns about increased workload and altered workflow, which could hinder the sustainability of the digital health technologies.Additionally, these newly implemented technologies would require additional purchase time and increased set-up, implementation, training, access, adaptation, and establishment stages.In addition, healthcare professionals commonly stressed that digital health technologies would impact the quality of delivered care, as recently trained professionals would need a longer time to convert acquired data into the implemented system.However, although time might be required to acquire the right skills and operating competencies, with adequate training, continuous technical support, and peer-to-peer collaboration, threats associated with increased time to complete a specific task are significantly reduced.Useful written guidelines, instructions, and handouts appear to be important facilitators that could be easily implemented 73 .Likewise, incentives from government agencies and multisectoral organizations were shown to significantly improve digital health technologies' effectiveness and chances of success in large-scale healthcare systems.Therefore, this conceptual perspective should be shown to healthcare providers, as increased effectiveness is directly related to the appropriate use of time and less wasteful processes.Fourth, legal-and ethical-related barriers were shown to be a relevant factor for healthcare providers, as privacy and security concerns, national legislation, jurisdiction, and the existence of unclear legal liability regarding response protocols would directly affect healthcare professionals.Possible interventions for these barriers are associated with the development of safer data storage systems, the establishment of requirements on safety and security in cooperation with healthcare professionals and patients, or the creation of an international legal framework and legislative norm, which would clarify security regulation policies that could help ensure patients' privacy and confidentiality, as well as define healthcare professionals' liabilities.
Lastly, deficient or inexistent training and educational activities were evidenced to significantly impact the success and efficiency of digital health technologies in the healthcare environment .Some reviews highlighted that without training, healthcare providers tend to feel low self-efficacy when utilizing any digital health technologies, resulting in negative attitudes toward these Fig. 2 Overview of the network map of the most frequently identified terms among included studies.Please note that in the network visualization, items are represented by their label and by default also by a rectangles.The size of the label and the circle of an item is determined by the weight of the item.The higher the weight of an item, the larger the label and the circle of the item.The color of an item is determined by the cluster to which the item belongs.

% (95%CI) p (F) e−Health
Fig. 3 Relative frequency meta-analysis of most reported barriers for the use of digital health technologies by healthcare professionals.

% (95%CI) p (F) e−Health
Fig. 4 Relative frequency meta-analysis of most reported facilitators for the use of digital health technologies by healthcare professionals.Frequencies (expressed as % and their confidence interval) are distributed among each categorized facilitators as well as by healthcare technology modality.We downgraded one level of confidence in the evidence based on the methodological quality of included systematic reviews and not based on the methodological limitations of primarily included studies.The rationale is that the AMSTAR-2 tool has seven strict critical domains, which, if occurred at least once, decreases overall confidence by two levels.Nevertheless, since several experts have already suggested that the reporting of many items in the PRISMA statement is suboptimal, we believe that this lack of reporting or evaluation might be associated with a "mass effect", where researchers simply follow an inadequate pattern.Therefore, we decreased one level in the certainty of evidence instead of two levels on reviews' methodological limitations.b Coherence was rated as no or very minor concerns because the reviews' findings appropriately described the data's complexity, variation, and interconnectedness.Therefore, the available qualitative evidence provided no signs of contradictory, ambiguous, or incomplete data and competing theories or theoretical elements.We found the obtained data rich enough considering the complex and vast amount of data, the number of studies included, and their associated number of participants.d Based on the review questions expressed in each included review, we judged the body of data from these reviews to be fully integrated with each research question.
e Although most of our included reviews were classified as "very low methodological quality" using the AMSTAR 2 tool, we believe that the reported data is significant enough not to decrease the confidence level primarily based on the methodological quality.We analyzed a group of phenomena that could hinder or enable the use of DHTs by healthcare providers, and we did find any signs of unbalanced or one-sided.Data underlying the reviews' findings were sufficiently rich in terms of the number of studies and number of healthcare professionals.
technologies.In addition, as evidenced by healthcare workers, prior technology introduction, vendor training, in-depth seminars, workshops, or correlated training activities are unusual, and regular quality process assessment following implementation to ensure efficiency are also rare.Interestingly, reviews not only highlighted that training was fundamental to the success of using digital health technologies but also suggested that training per se would also be delivered through certain digital health technologies, such as mobile technologies and computers.Thus, the training offer positively affects healthcare professionals' experience with digital health technologies, especially when monetary incentives are added to this variable, given the time invested in obtaining the proper abilities to operate any digital health technologies.
Using the AMSTAR 2 methodological quality assessment tool, most reviews had a very critically low overall methodological quality, as shown in Table 5. Nine-nine reviews were classified as very low quality, six as low quality, and only three were rated to have a high methodological quality.Two top-ranked reporting inadequacies related to the lack of evaluating the presence and likely impact of publication bias (95.2%), and the disregard of the risk of bias when interpreting the results of the review (95.2%).Where judgment was lost, this generally associated with the lack of prior protocol (50.9%), absence of justification for excluding individual studies (88.8%), lack of risk of bias assessment from individual studies being included in the review (63.8%).
We mapped the aforementioned data and complementary results, as shown in Fig. 5 (also available for virtual access through the GitMind platform). 126As evidenced in supplementary information 3 (pp 9), we found several terms with similar semantic structures.Thus, we coded each barrier or facilitator and identified recommendations, suggesting the possibility of a complex and broad linguistic connection and relationship amongst codes.These thematic relationships are not limited in our analysis and can be explored and exhausted.

DISCUSSION
To our knowledge, this is the first overview of systematic reviews to collate, cluster, and synthesize the quantitative, qualitative, and mixed methods body of literature associated with barriers and facilitators to and use of several digital health technologies by healthcare professionals at all levels of care.The decision for carrying out this valuable, but complex study, relies on the noticeable detachment of research data and investigation groups in the field of Medical Informatics, who usually inadvertently duplicate technical and financial resources given the existing gaps in the literature.Here we report 21 overarching barriers and 19 facilitators, mostly interconnected, containing a complex sequence of thematic describers and identifiers.Understanding and overcoming identified barriers to the fully integrated and coordinated use of DHTs by any class of healthcare providers and evaluating its facilitators could positively impact successful creation, implementation, adoption, training, and long-term services or product utilization.
The evidence suggests that healthcare providers and managers predominantly face infrastructure, technical-, training-, legal-, ethics-, time-, and workload-related barriers to using digital health technologies, regardless of the level of care or digital technology.In the second level of semantic occurrence, several restraining factors to the wide use of digital health technologies were combined and reported, including psychological and personal barriers, lack of supervisory support, ownership issues, and healthcare system-cultural-, social-, and financial-related limiting features.Nevertheless, we are aware that some of the classified items are interconnected, meaning that the prevalence of occurrence ranking should not be used as a priority guide for policymakers and health organizations when addressing these barriers.For instance, the highlighted barrier "81B" (regarding the simplicity of contents usually transferred in mobile applications or clinical alert systems) might be directly related (or potentially caused due to) to the technical limitations per se (considering devices screen's reduced size ("2B"), the complexity of the systems themselves and the information they carry ("5B"), or even because the lack of standardization and customizability of such systems and technologies ("7B").Therefore, the creation of artificial intelligence-based mind mapping representing these interconnections is of utmost relevance 126 .
Creating and applying digital health technologies to healthcare environments must be driven by a regime of comprehensive assumptions instead of empirical models and processes.Our results corroborate with published systematic reviews that have already evidenced patient-reported barriers and facilitators to utilizing digital health solutions for self-care [127][128][129] .For instance, self-management of low-back pain using mobile health applications was mainly challenging due to information technology, usability-accessibility, quality-quantity of content, tailoring-personalization, and motivation-support barriers 127 .In contrast, flexibly structured and intuitive navigation, trustworthy content and sources, content accounting for individual needs and priorities, and the opportunity to influence the application design appeared as relevant facilitators affecting the uptake and utilization of digital health interventions for self-management of lower back pain 127 .Likewise, Powell and colleagues suggested that a lack of awareness, self-motivation, training, privacy, and security concerns are the most common patient-derived barriers to using electronic portals 128 .Emphasized facilitators correlated with use engagement by a leader (i.e., physician), free access and control over health information, and an adequate communication profile.Therefore, as the relationships between our identified barriers and facilitators and existing patient-related evidence highlight, the development of digital healthcare solutions should consider multiple factors, which can facilitate or deteriorate broad goals of high-quality use of information technology in the healthcare environment.
During protocol modeling, our research group discussed the possibility of including reviews that summarize evidence on barriers and facilitators involving students in health fields.The decision was not to include these reviews because these students are not yet legally considered professionals or critically necessary workforce, and they are not considered essential in healthcare settings 130,131 .However, one aspect found in these excluded reviews was revealed in our overview with significant frequent and relevant findings: the use of digital health technologies for training and educational purposes.Although distance education dates from 1728 132,133 , e-learning or virtual learning started during the early 1980s at the University of Toronto 134 and has been developing ever since, particularly during the COVID-19 pandemic 135,136 .Currently, several high-income countries, such as New Zealand and the United States of America, have already integrated and implemented the Information and Communication Technology constructivist learning model in their national or statewide policies, ensuring that students have the chance to become digitally competent citizens 137,138 .These actions effectively decrease multiple barriers observed related to limited or no computer skills, restricted knowledge and technology literacy, and lack of reliability in technological tools.However, it has been suggested that numerous low-and middle-income countries still struggle with device acquisition, connectivity issues, tutors' level of expertise and lack of motivation, absence of basic infrastructure, and the unwillingness of the government to implement such solutions 129 .
Foremost, we chose only six health solutions as systematic and feasible choices for comprehensive data processing.Nevertheless, we observed additional modalities of health solutions being implemented worldwide (e.g., laboratory and radiology automatic reporting systems, picture archiving and communication systems, cloud-based systems, and advanced and business analytics), and our synthesis may miss emerging or recent technologies 52,74,114 .
For instance, studies have suggested that electronic laboratory reporting systems not only improve surveillance for notifiable conditions but can also be helpful in real-time laboratory testing in emergency departments and significantly improve organizational framework and efficiency 139,140 .Correspondingly, cloud-based computing systems have been increasingly applied in the healthcare system to ensure secure storage, handling, and processing of medical information 141 .Regardless of the digital health solution being implemented and utilized, healthcare workers and patients benefit from it.By improving real-time patient access to their results and providing better patient involvement with care, the incidence of unwanted tests or extra prescriptions decreases, and the overall quality of care is subsequently enhanced 142,143 .We observed a limited number of reviews assessing the potential challenges and enablers for artificial intelligence models, machine learning algorithms, and platforms utilizing features such as augmented reality 40,54,63,70,78,85,94,99 .However, although the restricted number of studies assessing these subgroups in the field of digital technologies, core barriers and facilitators remained like other subgroups.Nevertheless, we highlight the need for further research with these technologies, as alternative barriers and facilitators would arise.
Due to the wide variety of digital health technologies currently being used in several medical specialties and levels of care, we had to restrict our report in different ways, limiting our certainty of evidence.Similarly, our series of analyses did not consider the existence of subgroup singularities by type of healthcare professional.As suggested in our map based on bibliometric data, only physicians, community health workers, and nurses appeared as recurrent keywords among all studies within the 42 systematic reviews eligible for inclusion.Therefore, studies analyzing impeding and enabling factors to the general use of digital health technologies in other healthcare providers (e.g., pharmacists, physiotherapists, physical educators, speech therapists, healthcare governmental agents, biologists, social services agents, healthcare managers, dentists, and psychologists) cause a "professional class bias" event that should be addressed in future studies.Likewise, factors like age, racial group, gender, country income index, or geographic location could affect a different subgroup (e.g., potential higher reporting of barriers of professionals practicing in low-or middle-income countries would focus more on technical and infrastructure features).Moreover, we neglected that digital health technologies utilized in the healthcare environment are usually concomitant and integrated.Thus, we may have considered the reported health solution independently instead of using a translational and adapted assignment methodology.Therefore, the provided RFO represented only the tendency of domain observance and reporting and not the identical picture of healthcare professionals' reality.To conclude, we are aware that some highlighted barriers and facilitators could be assigned to a broader subtheme (e.g., lack of supervisory support in training and educational skills).However, during the overall execution, we observed that some terminologies and coding were commonly reported separately, so we decided to maintain them as individual elements to ensure the representativeness of the findings.Interestingly, the use of the AMSTAR 2 tool for evaluating the methodological quality of all included reviews should also be stated as a limitation, as the approach was primarily intended to systematic reviews of randomized controlled trials.Nevertheless, as most AMSTAR domains are on the elements that any review is structured (e.g., search strategy, protocol, extraction, combing studies, and publication bias), we believe that applying this methodology to our include reviews do not hinder the observed results.Likewise, although we Apart from these minor methodological limitations, the major strength of our study is the strict adhesion to international guidelines for reporting of systematic reviews (e.g., Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook of Systematic Reviews and Meta-Analyses) and the execution of the entire study with international and blinded collaboration.We acknowledge that more than one methodology for evaluating the certainty of the evidence in qualitative research exists.We applied the GRADE CERQual method to check the overall quality of evidence for the seven most-reported barriers and facilitators.Generally, the evidence quality is high, with all considered domains without major concerns but with methodological limitations.We judged this domain as a moderate concern based on the phenomena of interest, adequate data collection and extraction, and quality in reporting observed data.In addition, expert groups have been discussing.
Although digital health technologies and their numerous types of technologies positively affect the healthcare environment, barriers impacting the successful creation, adoption, implementation, and sustainability of digital interventions are commonly reported by healthcare workers.Notwithstanding, the identification and deployment of different enabling factors allow the utilization of digital technologies in a holistic and integrated way.This overview of reviews emphasizes remarkable limiting features that should be considered by all stakeholders and provides advice to overcome these issues, with the expectation of increasing professional satisfaction and, perhaps, the quality of delivered care.

METHODS
This overview of systematic and scoping review (herein referred to as "overview") protocol was registered on PROSPERO (CRD42022304372, supplementary information 4, pp 10-20) and it was part of a broader study conducted by the Data and Digital Health Unit of the Division of Country Health Policies and Systems of the World Health Organization, Regional Office for Europe 3 .This     initiative provides strategic direction, technical assistance, and tailored support to countries and policymakers to strengthen their capacity to generate timely, credible, reliable, and actionable health-related data.The scientific community is currently defining an explicit, systematic, and transparent methodology to create evidence-and agreement-based reporting guidelines for overviews of reviews 144 .Therefore, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting recommendations 145 , the Cochrane Handbook guidelines 146 , and reports published by Fusar-Poli et al. 147 and Cornell et al. 148 guiding the practice on how to effectively conduct an umbrella review.As our study relies upon secondary data, ethics approval was waived.It is worthwhile mentioning that although in our protocol we initially stated that a standard meta-analysis would not be carried out, we decided to mathematically evaluate the obtained results.The technique utilized for the word-and sentence-based assessment (particularly associated with discourse analysis) is a well-known summarizing strategy used in the field of Human Sciences and was systematically presented and implemented in our research team after the protocol preparation.Therefore, in consonance with the requirements of continuous scientific evolvement and improvement, we decided to apply this newly introduced technique.However, this deviation does not alter the core of this project.

Data sources and searches
We searched five databases (Cochrane Database of Systematic Reviews, Embase ® , Epistemonikos, MEDLINE ® , and Scopus) and the PROSPERO protocol registration platform from inception to Jan 23, 2022, for systematic and scoping reviews evaluating barriers and facilitators to using digital health technologies by healthcare professionals worldwide.We also performed a manual search of reference lists of reviews shortlisted for full-text review and planned to contact the authors of included review to retrieve additional data.An experienced information specialist and the expert team tailored search strategies to each database using Medical Subject Headings (MeSH) and free-text identifiers associated with the research topic [149][150][151][152] .The search included three main categories of key terms.Digital health technologies search identifiers included terms such as "telemedicine," "telehealth," "mobile health," "mHealth," "artificial intelligence," "machine learning," "social media," "natural language processing," and "computer decision support systems," healthcare professional-related terms included "healthcare worker," "healthcare provider," and "healthcare support worker," and systematic review filters used were "systematic review," "meta-analysis," and "scoping review."Our terms are defined in recently published studies in the World Health Organization guidelines on digital health technologies for strengthening health systems, the World Assembly Resolution on Digital Health, and The Lancet Digital Health.In supplementary information 5 (pp 21-28), we present the detailed search strategy for the databases.

Study selection
Eligibility was evaluated by two independent investigators who primarily screened titles and abstracts and subsequently reviewed the full texts using Covidence ® (Veritas Health Innovation, Melbourne, Australia) 153 .Systematic and scoping reviews deemed eligible must have used at least two databases for their assessment, should have described the search methods, and evidenced the use of a transparent methodology for study selection and data extraction.Moreover, these reviews were only included if a qualitative analysis of barriers and facilitators to using digital health technologies by healthcare providers was clearly noted.We did not place limits on targeted healthcare professionals, medical specialty, level of care, language, and publication date.However, in order to avoid bias and results inflation, those studies strictly prioritizing the assessment of digital technologies for students and education in the field of health sciences were excluded.
Data extraction and quality assessment Two independent researchers appraised the methodological quality of included systematic reviews using the AMSTAR-2 tool 154 .Following the initial evaluation, a third researcher crosschecked rated domains.The methodological quality of reviews was classified as "critically low," "low," "moderate," and "high."Our research team is aware that the AMSTAR 2 tool is not intended to generate an overall score of the review's quality.Thus, we emphasize that we considered the appraisal methodology holistically, mostly related to the provision of an extensive evaluation of quality, particularly weaknesses associated with poor conduct of the review or word counting limitation endorsed by a determined journal.
Relevant data (first author identification, publication year, published journal, number of included databases, review objectives, primary study design, type of healthcare professional, type of digital technologies being analyzed, number of included primary studies, and barriers, facilitators, and recommendations for using digital health technologies) was extracted from included reviews by two independent researchers using Microsoft Excel (Microsoft Corporation, Redmond, USA) 155 .In the second stage, four independent volunteer collaborators reassessed extracted data to resolve inconsistencies.

Data synthesis and analysis
We used VOSviewer to assess research hotspots associated with digital health technologies based on the principle of cooccurrence analysis 156 .The minimum number of co-occurrences was set as 3, normalization method as an association, random starts as 1, random seed as 0, resolution as 1, and we merged small clusters.We attempted to clean the network map as much as possible, as some keywords were not meaningful.Thus, we extracted data from the top 100 author-provided keywords and mapped them into a single keyword co-existing network.Representative and frequent terms are expressed as larger nodes, and the thickness of the link between two or more nodes represents the strength of the relationships between them.
Our findings were evaluated and collated using an adapted version of a thematic synthesis developed by Thomas and Harden 157 .The 21 domains prioritized in the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement were followed 158 .First, qualitative data of included reviews on the main barriers and facilitators identified were coded line-by-line using QSR's NVivo software (QSR International, Burlington, USA) 159 .In addition, primary highlighted concepts were re-evaluated by four volunteer collaborators who doublechecked selected data and evaluated extraction errors or missing information.If needed, they also created new in-text selections.Furthermore, we organized free selections into similar themes to combine the preliminary results into descriptive themes.Lastly, we developed analytical themes that summarized barriers and facilitators closely related to the original remarks reported in included reviews.The explanatory delineation of thematic barriers and facilitators was a dynamic, deductive, and intuitive process, as different review authors had their peculiarities in academic and text writing.The alignment of thematic barriers and facilitators was discussed by all authors, resulting in the development of recommendations.In the result section, we have identified only the five most frequent barriers and facilitators.Recommendations were also emphasized for these five features.However, a complete list of barriers, facilitators, and recommendations can be accessed in supplementary information 2 (2.1 and 2.2).Where homogenous barriers were recognized (e.g., lack of leadership and local

1 . 2 . 7 .
Offering training and educational activities increase the positive experience and facilitate the adoption of DHTs by healthcare providers 3.8% (95% CI 1.6-9.0)Moderate concerns No or very minor concerns No or very minor concerns No or very minor concerns High confidence Those healthcare professionals who perceived the full usefulness of DHTs and were willing and opened to the new technology are more likely to use them in a long-term period 3-to-use and intuitive navigation systems facilitate the use of DHTs by healthcare providers 1The existence of solid leadership and local champion facilitate the creation, implementation, and long-term adoption of DHTs by healthcare professionalsFeeling of reliability in utilized equipment and technologies improve the implementation and the adoption of DHTs by healthcare providers 1.7% (95% CI 0.7-3.8)Moderate concerns No or very minor concerns No or very minor concerns No or very minor concerns High confidence CI Confidence Interval, DHTs Digital Health Technologies, RFO Relative Frequency of Occurrence. a c

B
Ba ar rr r r r r r i ie er r i i r r de dent nti if fi i f f f f e er r f f r r ol ol f f f f l low owe ed by pot d by pote ent nti ia al l f fa a f f f f c ci il li it ta at tor or or or r r r r r r e ec com omm me enda ndat ti ion on I Inf nfr r f f f f a as st tr ruc uc r r r t tur ur t t t t e e a and t nd te ec chni hnic ca al l ba bar rr r r r r r i ie er rs sTTi im me e a and w nd wor orkl kl r r r oa oad-d-r re el la at te ed ba d bar rr r r r r r i ie er rs s T Tr r T T T T a ai ini ning a ng and e nd educ duca at ti iona onal l ba bar rr r r r r r i ie er rs s L La ac ck of k of s s f f upe uper rvi vi r r r s sor ory s y s r r r uppor upport t r r r O Ow wne ner rs shi hip i p is ss sue ues s H He ea al lt th s h sys yst te em m-r re el la at te ed a d and f nd fi i f f f f na nanc nci ia al l ba bar rr r r r r r i ie er rs s C Cul ult tur ur t t a al l, s , soc oci ia al l, a , and f nd fi i f f f f na nanc nci ia al l ba bar rr r r r r r i ie er rs s P Pe er rs sona onal l a and ps nd psyc ychol hologi ogic ca al l ba bar rr r r r r r i ie er rs s O Or rga ga r r ni niz za at ti iona onal l-r re el la at te ed ba d bar rr r r r r r i ie er rs s L Le ega gal l-a and e nd et thi hic ca al l-r re el la at te ed ba d bar rr r r r r F .Fe ea ar r of of r r l l f f os osi ing pa ng pat ti ie ent nts s 57B 57B.M .Me edi dic ca al l r re es spons ponsi ibi bil li it ty y t t 58B 58B.L .La ac ck of k of c c f f om omput put m m m e er r l l r r i it te er ra ac cy y 59B 59B.L .La ac ck of k of hum hum f f a an i n int nte er ra ac ct ti ion on 60B 60B.P .Pr rof ofe e f f f f s ss si iona onal l s ske kept pti ic ci is sm m 61B 61B.A .Aw w A A A A e ea ar rne ne r r r r s ss s of of t t f f e ec chnol hnology e ogy exi xis st te enc nce e 62B 62B.R .Ri is sk-k-be bene nef fi i f f f f t t a a t t s ss se es ss se em me ent nt 63B 63B.O .Out utc com ome es s e expe xpec ct ta anc ncy y 64B 64B.S .Soc oci iode odem mogr ogra aphi phic c c cha har ra ac ct te er ri is st ti ic cs s 65B 65B.S .Sa at ti is sf fa a f f f f c ct ti ion w on wi it th t h the he c cont onte ent nt a a t t va vai il la abl ble e 66B 66B.M .Mi inor nori it ti ie es s i is ss sue ues s 67B 67B.T .Te e T T T T c chnophobi hnophobia a 28F 28FR R. A .Ada dapt pt D D t t H HT Ts s T T T T t to he o hea al lt thc hca ar re e pr prof ofe e f f f f s ss si iona onal ls s ne nee eds ds c cons onsi ide der ri ing t ng the hei ir r e e r r c conom onomi ic c a and s nd soc oci ioc ocul ult tur ur t t t a al l ba bac ckgr kground ound 27F 27FR R. E .Expl xpla ai in c n cl le ea ar rl ly t y the he f func unc f f f f t ti ions ons of of e e f f a ac ch D h DH HT Ts s T T T T 26F 26FR R. D .De em mons onst tr ra at te e D DH HT Ts s T T T T ' ' e ef ff f f f f f e e f f f f c ct ti ive

Fig. 5
Fig. 5 Conceptual map of reported barriers and potential facilitators and recommendations to overcome these barriers.

Table 1 .
Main characteristics of included studies evaluating the impact of digital health solutions on health workers (n = 108).

Table 1 continued
PubMed, CINAHL, and PsycINFOTo identify, categorize, and summarize knowledge about different stakeholders' (e.g., children and adolescents, parents, HCPs, policy makers, and designers of patient portals or PAEHRs) views, use, and experiences of EHR access for children, adolescents, and parents.
4PubMed, CINAHL, Web of Science, and ScienceDirect To examine physician burnout issues incident to the EHR prior to and during the first year of the COVID-19 pandemic by analyzing the literature from the last 5 years

Table 1 continued
6 Medline, Scopus, PsychINFO, CINAHL and Cochrane Library, Google To identify HCPs perspectives on barriers to, and facilitators of, mobile phone based SRH services and information in rural areas of LMICs from current literature.13 MEDLINE, Embase, CINAHL, SSCI, Global health, Eldis, Google Scholar, mHealth database, mHealth Evidence, mHealth Knowledge, mPowering, OpenGrey, and Grey Literature To synthesize qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others 53

Table 1 continued
MEDLINE, Embase, Cochrane Library of Systematic Reviews, CINAHL, PsycINFO, ProQuest, Conference Proceedings Citation Index, and Google search To investigate factors (barriers and facilitators) influencing the adoption and implementation of electronic consultation (eConsult services) to enhance access to speacialist care 3 PubMed, CINAHL, and Scopus The purpose of this scoping review is to characterize the recent original peer-reviewed research studies on the e-professionalism of HCPs; to assess the quality of the methodologies and approaches used; to explore the impact of SM on e-professionalism of HCPs; to recognize the benefits and dangers of SM; and to provide insights to guide future research in this area 5 PubMed, Embase, Web of Science, Cochrane Library of Systematic Reviews, and Scopus To summarize findings regarding the use of telemedicine across the 53 member states of the WHO European Region and to identify the medical fields and levels of care in and at which the effectiveness, feasibility, and applicability of telemedicine have been demonstrated

Table 2 .
Population being evaluated, studies' methodologies and technologies being evaluated.

Table 2 continued
CDSS Computerized Decision Support Systems, HIV Human Immunodeficiency Virus, ICD-10 International Classification of Diseases, 10th version, ICU Intensive Care Unit, m-Health mobile health technologies, N/A Not applicable or not available.

Table 3 .
Top author-provided identifiers among included reviews.

Table 4 .
Summary of qualitative findings.

Table 5 .
Quality assessment rating of systematic reviews included in the digital health solutions applied to healthcare workers environment overview.

Table 5 continued
a age ge of of e e f f l le ec ct tr roni onic c de devi vic ce es s a and s nd sof oft t f f f f w wa ar re es s 2B 2B.S .Sm ma al ll l de devi vic ce es s s sc cr re ee ens ns HT Ts s T T T T t to he o hea al lt thc hca ar re e pr prof ofe e f f f f s ss si iona onal ls s ne nee eds ds 6F 6FR R. I .Invol nvolve vem me ent nt of of t t pr pr f f ovi ovide der rs s t thr hroughout oughout t t t t he he de deve vel lopm opme ent nt pr pr t t oc oce e 1F 1FR R. P .Pr rom omot ote e t the he de deve vel lopm opme ent nt of of t t us us f f e ef ful ul f f f f D DH HT Ts s T T T T t thr hrough c ough col oll la abor bora at ti ion on be bet tw we ee en i n invol nvolve ved s d st ta ake kehol holde der rs s 2F 2FR R. I .Inc ncr re ea as se e t the he a ava vai il la abi bil li it ty y, pur , pur y y y y c cha has se e, a , ac cc ce es ss s t to e o el le ec ct tr roni onic c de devi vic ce es s a and nd i inc ncr re ea as se e t the he a ac cc ce es ss s t to hi o high-gh-qua qual li it ty a y and s nd spe pee edy i dy int nte er rne ne r r r r t t c c t t onne onnec ct ti ion on 3F 3FR R. C .Cr re ea at te e D DH HT Ts s T T T T w whi hic ch a h ar re e e ea as sy-y-t to-o-us use e a and ha nd have ve a an i n int ntui ui t t t t ti ive ve na navi viga gat ti ion on 4F 4FR R. C .Cr re ea at te e pr progr ogra am ms s f f c ct ti ive vene nes ss s out outc com ome es s ba bas se ed on out d on outs st ta andi nding publ ng publi ic ca at ti ions ons 25F 25FR R. I .Ide dent nti if fy a y a f f f f l lt te er rna na r r r r t ti ive ves s f for or f f f f t t r r he he de dec cr re ea as se ed i d in-n-pe per rs son i on int nte er ra ac ct ti ion on Es st ta abl bli is sh a h and c nd cr re ea at te e s st ta anda ndar rd a d and i nd int nte er rna na r r r r t ti iona onal l l le ega gal l a and e nd et thi hic ca al l c code odes s t oll le egue gues s t tow owa ar rds ds t the he t te ec chnol hnology ogy 18F 18FR R. E .Es st ti im mul ula at te e t the he e es st ta abl bli is shm hme ent nt of of t t a a f f he hea al lt thy hy a and pos nd posi it ti ive ve pr prof ofe e f f f f s ss si iona onal l e envi nvir ronm onme ent nt 16F 16FR R. C .Cr re ea at te e gui guide del li ine nes s a and nd pr prot otoc ocol ols s f for or