Understanding inherent influencing factors to digital health adoption in general practices through a mixed-methods analysis

Extensive research has shown the potential value of digital health solutions and highlighted the importance of clinicians’ adoption. As general practitioners (GPs) are patients’ first point of contact, understanding influencing factors to their digital health adoption is especially important to derive personalized practical recommendations. Using a mixed-methods approach, this study broadly identifies adoption barriers and potential improvement strategies in general practices, including the impact of GPs’ inherent characteristics – especially their personality – on digital health adoption. Results of our online survey with 216 GPs reveal moderate overall barriers on a 5-point Likert-type scale, with required workflow adjustments (M = 4.13, SD = 0.93), inadequate reimbursement (M = 4.02, SD = 1.02), and high training effort (M = 3.87, SD = 1.01) as substantial barriers. Improvement strategies are considered important overall, with respondents especially wishing for improved interoperability (M = 4.38, SD = 0.81), continued technical support (M = 4.33, SD = 0.91), and improved usability (M = 4.20, SD = 0.88). In our regression model, practice-related characteristics, the expected future digital health usage, GPs’ digital affinity, several personality traits, and digital maturity are significant predictors of the perceived strength of barriers. For the perceived importance of improvement strategies, only demographics and usage-related variables are significant predictors. This study provides strong evidence for the impact of GPs’ inherent characteristics on barriers and improvement strategies. Our findings highlight the need for comprehensive approaches integrating personal and emotional elements to make digitization in practices more engaging, tangible, and applicable.

Background: Extensive research has already shown the potential value of digital health solutions and highlights the importance of clinicians' adoption.As general practitioners (GPs) are patients' first point of contact, identifying barriers to adoption and potential strategies for improvement is especially important.In this context, extensive research has studied digital health adoption across various medical disciplines, healthcare settings, and technologies.However, only a few studies considered a broader perspective on adopting digital health solutions and investigated potential strategies to improve adoption.Thus, we aimed to identify and synthesize relevant barriers and improvement strategies across technologies relevant to general practice settings.Methods: For our scoping review, we searched the PubMed and PsycINFO databases on 20 February 2023 and manually deduplicated the results.We narrowed initially identified citations to studies published in English or German between January 2018 and December 2022 to account for more recent research findings.We included all articles that focused on clinician populations, digital health solutions, and general practice settings that addressed, measured, and reported factors impacting or promoting the adoption or use of digital health solutions.We included only peer-reviewed articles, as we aimed to identify validated barriers and strategies.We synthesized evidence from the included studies by extracting and grouping potentially relevant barriers and improvement strategies to digital health adoption.
Findings: Of 1276 records initially identified in the two databases, 24 were eligible.Most studies were quantitative (11/24; 46%) and focused on GPs' (17/24; 71%) adoption of mHealth applications SECTION ITEM PRISMA-ScR CHECKLIST ITEM REPORTED IN SECTION (6/24; 25%).While there was a large variability of digital health solutions targeted in the studies, most did not look at specific conditions to be treated (16/24; 67%) or utilized theoretical models to describe digital health adoption (16/24; 67%).More than 90% of included studies report organizational barriers to digital health adoption (23/24), with more than half demonstrating that high workload and a lack of time (each 14/23; 61%) are predominant barriers to adoption.Another 88% of studies identify social adoption barriers (21/24).Of these, GPs' familiarity with digital health solutions (17/21; 81%) was the most cited barrier to adoption, followed by overall awareness (10/21; 48%) and patient preferences (10/21; 48%).Looking into potential strategies to support digital health adoption, around two-thirds of studies identify strategies related to developing digital health solutions as potentially helpful to improve adoption (16/24; 67%).Among these, the most frequently cited aspects are those that improve the usefulness of digital health solutions (13/21; 62%) Interpretation: Many studies investigate the adoption barriers of GPs regarding digital health solutions.However, they primarily focus on dedicated technologies and adoption barriers instead of an integrated perspective.To date, many adoption barriers have been identified, while only a few studies investigate potential strategies to support the adoption by GPs.

Rationale 3
Describe the rationale for the review in the context of what is already known.Explain why the review questions/objectives lend themselves to a scoping review approach.
Extensive research has already shown the potential value of digital health and the importance of GPs' adoption regarding the success of these technologies.Since GPs are patients' first point of contact, identifying factors impacting and promoting their adoption of digital health is crucial.Many studies have identified barriers and improvement strategies for dedicated digital solutions.However, most of these have applied an overarching perspective, while these barriers might be impacted by factors inherent to the GP.Thus, this review aims to provide a comprehensive understanding of barriers and improvement strategies to allow a subsequent mixed-methods study to investigate the impact of GPs' inherent characteristics.

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Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.
Our review aimed to more broadly identify currently postulated perceived barriers and potential improvement strategies for digital health adoption across technologies.With this, a subsequent mixed-methods study would allow us to (1) create transparency on perceived barriers and improvement strategies to digital health adoption of GPs in Germany and (2) assess the role of personality traits and other inherent characteristics as underlying influencing factors.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.
As this review was part of a mixed-methods approach, we did not prepare, register, and publish a review protocol.

Eligibility criteria 6
Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.
see 'Literature Review'

Information sources 7
Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.
see 'Literature Review' Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.
We developed a data extraction sheet listing all the relevant data we needed to extract from the eligible studies.According to the sheet, LW extracted all data from eligible studies.All data were extracted as reported in the studies and compared after extraction to harmonize wording across studies.

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made.
We sought data for all factors impacting or promoting digital health adoption reported in the eligible studies, i.e., that were reported as part of a quantitative assessment or a theoretical model.In addition, we sought data on study-related characteristics.We extracted information from each eligible report on (1) the report itself (including author, publication year, journal, and publication identifier); (2) the study itself (including sample characteristics, sample size, and study location); (3) the research design (including the study design and theoretical framework utilized); (4) the intervention (i.e., the type of digital health solution under consideration and the condition treated).

Critical appraisal of individual sources of evidence 12
If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).
We did not conduct a dedicated critical appraisal of included studies as we aimed to identify factors impacting or promoting digital health adoption as presented in multiple studies and only included evidence from more than one study and aimed to validate the results of our literature review in qualitative expert interviews with GPs, ensuring relevance and completeness of extracted barriers and improvement strategies.

Synthesis of results 13
Describe the methods of handling and summarizing the data that were charted.see 'Literature Review' First, as we limited our search to peer-reviewed articles published in German or English and excluded grey literature, we might not have identified all literature relevant to our research question and potentially encountered a publication bias.In addition, our inclusion and exclusion criteria defined before our search also limited our approach.

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Second, as we further limited our search to articles published in the last five years, we might have missed older evidence.Thus, we might not have captured all factors impacting or promoting digital health adoption proposed in the literature.As the COVID-19 pandemic has accelerated the adoption of digital health, we aimed at capturing more recent evolvements.

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Third, as our review was part of a more extensive mixed-methods study, our search, data extraction, and synthesis were solely conducted by one author and not validated by a second reviewer.We are confident, that this would not have changed our synthesis of results as we validated these externally via expert interviews.

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.
Many studies investigate GPs' adoption barriers regarding digital health solutions.However, they mainly focus on dedicated technologies and conditions instead of an integrated perspective.This finding aligns with other reviews targeting digital health adoption for dedicated technologies.Many adoption barriers have been identified, while only a few studies look into potential strategies to support adoption.However, recent reviews highlight the importance of social factors for digital health adoption, which we echo in our findings.As no single approach to enhancing digital health adoption applies to all GPs, we call for analyzing personality and other inherent characteristics as potential influencing factors on digital health adoption.We believe that exploring personality as a potential underlying factor relevant to digital health adoption is particularly important in general practices as (1) digitalization in general practices is mainly driven by GPs themselves and thus will not be pursued unless they deem it necessary, (2) there is already some evidence highlighting the role of personality for patients' adoption of digital health solutions.FUNDING

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review.Describe the role of the funders of the scoping review.
As this research is part of a doctoral thesis at Witten/Herdecke University, it has not received any funding.There was no relationship established to the participants prior to the study.

Participant knowledge of the interviewer 7
What did the participants know about the researcher?(e.g., personal goals, reasons for doing the research) In the beginning of the interview, participants were informed about the educational and professional background of the researcher, and the overall objectives and aims of the research.

Interviewer characteristics 8
What characteristics were reported about the interviewer/facilitator? (e.g., bias, assumptions, reasons, and interests in the research topic) Participants were informed that the interest in the research topic was based on the researcher's professional background.

Methodological orientation and theory 9
What methodological orientation was stated to underpin the study?(e.g., grounded theory, discourse analysis, ethnography, phenomenology, content analysis) As we purposively sampled participants, we were able to include diverse age ranges and work experience levels as well as locations and practice types.However only 20% of interviewees were female.On average, participants were 53 years old and have worked as a general practitioner for 18 years in a city with 105k inhabitants.Four general practitioners worked in a single practice, five worked in a group practice and one worked in a medical care center.

Interview guide
Were questions, prompts, guides provided by the authors?Was it pilot tested?see 'Expert interviews' We utilized a semi-structured interview guide for the interviews to allow for flexibility yet achieve standardization of the interview procedure.We did not ask for feedback on the findings from participants.

Quotations presented 29
Were participant quotations presented to illustrate the themes/findings?Was each quotation identified?(e.g., participant number) We do not present participant quotes.

Data and findings consistent 30
Was there consistency between the data presented and the findings?Data presented and findings are consistent.

Clarity of major themes 31
Were major themes clearly presented in the findings?
see 'Adoption barriers and improvement strategies in general practices (literature review and expert interview results)' The section provides a quantitative overview of interview themes and their contrast with literature review results.We do not discriminate between major or minor themes.To prevent biases items can be randomized or alternated.
We did not randomize items as we chose the sequence of questions based on general questionnaire design guidelines.We asked participants to answer questions on their demographics, practice-related characteristics, digital health usage, affinity for technology interaction, and personality first (i.e., independent variables), before they had to answer the remaining items for dependent variables (i.e., digital maturity, adoption barriers, strategies to support adoption).

Adaptive questioning 15
Use adaptive questioning (certain items, or only conditionally displayed based on responses to other items) to reduce number and complexity of the questions.
As we partially utilized existing instruments, we did not use adaptive questioning in our survey.

Number of items 16
What was the number of questionnaire items per page?The number of items is an important factor for the completion rate.

see 'Online survey'
The total number of questions was 17, with demographics, practice-related characteristics, and digital health usage

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containing nine single-choice questions, affinity for technology interaction and personality each containing one Likert-type scale, and the remaining three sections each being spread across two survey pages and thus containing two Likert-type scales each.Across all questions our survey consisted of 116 items.

Number of screens (pages) 17
Over how many pages was the questionnaire distributed?The number of items is an important factor for the completion rate.
In general, sections (1) to (3) were displayed on separate questionnaire pages, while sections (4) to ( 6) were each split into two pages to reduce the number of items per page and allow for a more user-friendly completion of the questionnaire.In total, the survey was distributed over 12 pages, with nine questionnaire pages covering the different sections, one welcome and goodbye screen, and one screen to provide informed consent.

Completeness check 18
It is technically possible to do consistency or completeness checks before the questionnaire is submitted.Was this done, and if "yes", how (usually JAVAScript)?An alternative is to check for completeness after the questionnaire has been submitted (and highlight mandatory items).If this has been done, it should be reported.All items should provide a non-response option such as "not applicable" or "rather not say", and selection of one response option should be enforced.
We utilized forced responses for the first three sections and softforced-response (i.e., reminders to provide complete answers) for the latter.To enforce the selection of one response option and not undermine the forced response of the question, the survey did not provide an "I don't know" option.We applied both strategies to gain complete, meaningful responses, even though this might have led to a lower response rate.

Review step 19
State whether respondents were able to review and change their answers (e.g., through a Back button or a Review step which displays a summary of the responses and asks the respondents if they are correct).
We decided not to include a "back" button for respondents to review and change their responses to counter a potential social desirability effect that might cause them to change their responses after completing subsequent questions.

Unique site visitors 20
If you provide view rates or participation rates, you need to define how you determined a unique visitor.The number of people submitting the last questionnaire page, divided by the number of people who agreed to participate (or submitted the first survey page).This is only relevant if there is a separate "informed consent" page or if the survey goes over several pages.This is a measure for attrition.Note that "completion" can involve leaving questionnaire items blank.This is not a measure for how completely questionnaires were filled in.(If you need a measure for this, use the word "completeness rate".)see 'Online survey' and 'Figure 7'

Cookies used 24
Indicate whether cookies were used to assign a unique user identifier to each client computer.If so, mention the page on which the cookie was set and read, and how long the cookie was valid.Were duplicate entries avoided by preventing users access to the survey twice; or were duplicate database entries having the same user ID eliminated before analysis?In the latter case, which entries were kept for analysis (e.g., the first entry or the most recent)?
We decided not to use cookies to prevent multiple entries from the same individual, as general practitioners in one practice might share a computer.Thus, we would automatically exclude them from participating in the survey.

IP check 25
Indicate whether the IP address of the client computer was used to identify potential duplicate entries from the same user.If so, mention the period of time for which no two entries from the same IP address were allowed (e.g., 24 hours).Were duplicate entries avoided by preventing users with see 'Online survey' and 'Figure 7' We checked the anonymized IP addresses of participants to identify duplicate entries from the same individual.However, we only excluded IP address duplicates with identical demographic data to ensure that we would allow general practitioners working

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the same IP address access to the survey twice; or were duplicate database entries having the same IP address within a given period of time eliminated before analysis?If the latter, which entries were kept for analysis (e.g., the first entry or the most recent)?
in the same practice and thus sharing an IP address to participate in the survey.We kept the most recent and complete entry for the cases with identical IP addresses and demographic data.

Log file analysis 26
Indicate

Conclusion and goodbye
Supplementary Notes 2. Translated survey questionnaire for general practitioners.
Disclaimer: The questionnaire was presented to respondents in German.This copy was translated, only stating questions included in the publication.

Introduction ________________________________________________________
Dear Sir or Madam, Thank you for your interest in this study.
As part of a doctoral thesis at the Faculty of Health at Witten/Herdecke University, we are investigating the degree of digitalization of German general practices as well as your concerns and wishes regarding the adoption of digital health solutions.On this basis, we aim to derive relevant strategies that make it easier for general practitioners and decision-makers to advance the digitalization of the healthcare system.
In this study, we define digital health solutions as digital tools, technologies, and services to improve healthcare, make it more efficient, and personalize it.This includes the use of digital services (e.g., video consultations, digital telephone assistance system, digital appointment booking, digital medical history, digital practice administration) and the use of connected medical devices and artificial intelligence (e.g., telemonitoring, decision support systems).
This survey addresses practicing general practitioners in Germany.The survey will take about 10 to 15 minutes to complete.We would like to ask you to answer the questionnaire completely.
This research project has been approved by the Ethics Committee of Witten/Herdecke University (S-242/2022).On the following pages, you will find all the necessary information on data processing and your rights as a participant.To participate in this study, it is necessary that you electronically provide your informed consent afterward.
Thank you very much!

Information on data security and storage policies _________________________
Within this online survey, the personal data of the respondents will be collected and processed anonymously.The data collected is used purely for scientific purposes and cannot be traced to you personally.Due to the anonymous data collection, a subsequent deletion of your data is impossible.Your consent to the data protection regulations is voluntary and can be revoked in writing or verbally at any time without giving reasons and without personal disadvantage.
Show privacy policy.
I have read the information on the survey data processing and agree to participate in the study.

Questions about yourself and your job __________________________________
In the following, we would like to learn more about you as a person, your practice, and your interactions with digital health solutions.
By digital health solutions, we mean digital tools, technologies, and services to improve healthcare, make it more efficient, and personalize it.This includes the use of digital services (e.g., video consultations, digital telephone assistance system, digital appointment booking, digital medical history, digital practice administration) and the use of connected medical devices and artificial intelligence (e.g., telemonitoring, decision support systems).

Questions about your interaction with technical systems ___________________
In the following, we will ask you about your interaction with technical systems.The term 'technical systems' refers to apps and other software applications, as well as entire digital devices (e.g., mobile phone, computer, TV, car navigation).
Please indicate the degree to which you agree/disagree with the following statements.

Questions about your personality ______________________________________
In the following, we would like to learn more about you as a person.For each of the following statements, please indicate how much it applies to you.You can grade your answers from "does not apply at all" to "fully applies".

Questions about the digital maturity of your practice (part 1) ________________
In the following, we would like to know more about your practice.For each of the following statements, please indicate how much you agree with them.You can grade your answers from "strongly disagree" to "strongly agree".

Questions about the digital maturity of your practice (part 2) ________________
In the following, we would like to know more about your practice.For each of the following statements, please indicate how much you agree with them.You can grade your answers from "strongly disagree" to "strongly agree".

Questions about perceived barriers (part 1) ______________________________
In the following, we would like to learn more about barriers you perceive related to using or adopting digital health solutions.
As a reminder, we define digital health solutions (dhs) as digital tools, technologies, and services to improve healthcare, make it more efficient, and personalize it.This includes the use of digital services (e.g., video consultations, digital telephone assistance system, digital appointment booking, digital medical history, digital practice administration) and the use of connected medical devices and artificial intelligence (e.g., telemonitoring, decision support systems).
For each of the following statements, please indicate how much you agree with them.You can grade your answers from "strongly disagree" to "strongly agree".

Questions about perceived barriers (part 2) ______________________________
In the following, we would like to learn more about barriers you perceive related to using or adopting digital health solutions.For each of the following statements, please indicate how much you agree with them.You can grade your answers from "strongly disagree" to "strongly agree".The adoption of dhs requires adjustments to existing practice processes and workflows.
The implementation of dhs is costly and subsequent use is not adequately reimbursed.

¨ ¨ ¨ ¨ ¨
There is insufficient empirical evidence about the benefits of dhs for patients.
I do not have sufficient information on existing dhs and how they work.
The implementation of dhs will lead to an increased workload.
The implementation of dhs will require a high training and familiarization effort.

Questions about potential measures to support adoption (part 1) ____________
In the following, we would like to learn more about which aspects might encourage you to implement digital health solutions in your practice or might support you in doing so.
As a reminder, we define digital health solutions (dhs) as digital tools, technologies, and services to improve healthcare, make it more efficient, and personalize it.This includes the use of digital services (e.g., video consultations, digital telephone assistance system, digital appointment booking, digital medical history, digital practice administration) and the use of connected medical devices and artificial intelligence (e.g., telemonitoring, decision support systems).
For each of the following statements, please indicate how much you agree with them.You can grade your answers from "strongly disagree" to "strongly agree".…if providers improved the benefits for my practice and my patients.
…if providers optimized user-friendliness and ease of use.

Questions about potential measures to support adoption (part 1) ____________
In the following, we would like to learn more about which aspects might encourage you to implement digital health solutions in your practice or might support you in doing so.For each of the following statements, please indicate how much you agree with them.You can grade your answers from "strongly disagree" to "strongly agree".…if I had more information about the potential benefits for physicians and for patients.
…if there was additional research and information about the benefits and potential risks.
…if I had more information about available reimbursement and financing models.…if there were educational opportunities for patients about dhs and associated benefits.
…if competencies in the use of dhs were included in medical professional training.
…if there were financial incentives for the introduction or the reimbursement were improved.
…if policies and regulations were simplified and there were guidelines on medico-legal risks.
…if there were legal regulations that simplified data protection and handling of personal data.

Conclusion and goodbye _____________________________________________
You have reached the end of this survey.Your responses have now been recorded.
Thank you very much for your participation!Do you have colleagues who might also be interested in participating?If so, please forward the survey link to them: survey link.
You may now close the browser window.
like to see the use or introduction of dhs.

Table 4 . Consolidated criteria for reporting qualitative research (COREQ) checklist.
We planned to interview between 8 and 15 general practitioners based on data saturation.This was achieved, i.e., no new content on top of the derived themes based on the literature research emerged by the time we interviewed 10 general practitioners.

Table 5 . Checklist for reporting results of internet e-surveys (CHERRIES).
Data were anonymized following the principle of k-anonymity and stored solely on the Witten/Herdecke University server.We did not collect any personal information that could be tied back to individual respondents.DEVELOPMENT AND PRE-TESTING

RECRUITMENT PROCESS AND DESCRIPTION OF THE SAMPLE HAVING ACCESS TO THE QUESTIONNAIRE
The announcements used for recruitment varied slightly in length and style to match the audience and channel.Overall, we provided the different channels with a formal digital letter signed by the research team as an official invitation to participate in the survey, a digital flyer containing the most relevant information about the survey (i.e., research question, target group, survey duration), and the respective survey link.The formal letter included the following message (translated English version): "Dear Sir or Madam, The Chair of Health Informatics at Witten/Herdecke University is currently looking for participants for an online survey entitled 'digitalization in general practice settings -influencing factors and perceived barriers'.In the research project, the team investigates the degree of digitalization in German general practices, perceived barriers, and potential strategies for improvement concerning the adoption of digital health solutions.The survey, which takes about 15 minutes to complete, is aimed at practicing general practitioners with a practice location in Germany, regardless of their experience with digital health solutions.You are welcome to follow this link to participate in the survey: [survey link].If you have any questions or suggestions, please feel free to contact the chair team [mail address].".

Experience with digital health solutions ___________________________
whether other techniques to analyze the log file for identification of multiple entries were used.If so, please describe.
-Could you tell me a little about yourself (your age, professional experience, place of work)?-Could you tell me a little about your practice, including the type of practice and the patient population (statutory vs. privately health-insured patients)?-Do you have any experience with digital health solutions (e.g., video consultations, electronic patient records, e-prescribing)?-If so, which digital health solutions have you implemented in your practice?Part 2: Perspectives on indicators of digital maturity Part 3:

Preferable strategies to improve digital health adoption ______________
Policy-related strategies, i.e., strategies related to improvements in regulatory requirements, guidelines, and legal regulation for digital health solutions -In the aforementioned areas or beyond -which other activities or strategies do you think would support or encourage general practitioners to adopt digital health -How could the barriers you mentioned be overcome?-Whatwould encourage you (or has already encouraged you) to adopt digital health solutions?-Whatcould healthcare providers, policymakers, or other healthcare stakeholders do or what actions could they take to encourage you to adopt digital health solutions or support you in adoption?-On a scale of 1 (no need for action at all) to 10 (paramount need for action), how would you rate the need for action towards the goal of implementing digital health d.Implementation-related strategies, i.e., strategies related to improvements in the actual adoption of digital health solutions during implementation e.