RESEARCH

Effectiveness and safety of asynchronous

telemedicine consultations in general
practice: a systematic review
Cara Leighton, BSc1*, Alison Cooper, MBBh, PhD2, Annavittoria Porter, BSc1,
Adrian Edwards, MBBS, PhD2, Natalie Joseph-­Williams, PhD2
1
Cardiff University School of Medicine, Cardiff, UK; 2Division of Population Medicine
Cardiff University, Cardiff, UK

Abstract
Background: There is a focus on increasing asynchronous telemedicine use, which allows medical
data to be transmitted, stored, and interpreted later; however, limited evidence of the quality of care
it allows in general practice hinders its use.
Aim: To investigate uses and effectiveness of asynchronous telemedicine in general practice, according
to the domains of healthcare quality, and describe how the COVID-­19 pandemic changed its use.
Design & setting: Systematic review in general practice.
Method: A systematic search was carried out across four databases using terms related to general
practice, asynchronous telemedicine, uses, and effectiveness, and supported by citation searching.
This was followed by screening according to pre-­ defined criteria, data extraction, and critical
appraisal. Narrative synthesis was then undertaken guided by the six domains of healthcare quality
and exploring differences in use before and following the COVID-­19 pandemic.
Results: Searches yielded 6864 reports; 27 reports from 23 studies were included. Asynchronous
*For correspondence: ​ telemedicine is used by a range of staff and patients across many countries. Safety and equity are
[email protected] poorly reported but there were no major safety concerns. Evidence from other domains of healthcare
Twitter: @LeightonCaraH quality show effectiveness in making diagnoses, prescribing medications, replacing other consultations,
providing timely care, and increased convenience for patients. Efficiency is impacted by negative
Twitter: @adriangkedwards
effects on workflow, through poor implementation and patient non-­ adherence, limiting usability
Twitter: @NJosephWilliams and requiring new administrative approaches from healthcare staff. Asynchronous telemedicine use
increased rapidly from March 2020, following the COVID-­19 pandemic outbreak.
Competing interest: The authors
declare that no competing Conclusion: Asynchronous telemedicine provides quality care for patients but is limited by reports
interests exist. of increased workload and inefficient workflow compared with face-­to-­face consultations. Limits of
evidence include heterogeneity and small-­ scale studies. Further research into cost-­ effectiveness,
Received: 08 September 2023
Accepted: 19 September 2023 equity, safety, and sustained implementation will influence future policy and practice.
Published: 07 February 2024

‍ ‍This article is Open Access: CC

BY license (https://creativecom-
mons.org/licenses/by/4.0/)
How this fits in
Author Keywords: general Asynchronous telemedicine utilisation increased in general practice following the COVID-­ 19
practice, telemedicine, quality of pandemic outbreak as approaches to replace face-­to-­face consultations were required for safety
health care, primary healthcare, and infection control reasons, but there is little evidence of its effectiveness and safety. This review
general practitioners
found asynchronous telemedicine can be effective for making diagnoses, prescribing medications,
Copyright © 2024, The Authors; and providing timely care and increased convenience for patients. It takes equivalent time to face-­to-­
DOI:10.3399/BJGPO.2023.0177 face and telephone consultations, but is limited by reports of increased workload and poor workflow

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Box 1 Definitions of telemedicine, synchronous telemedicine, asynchronous telemedicine, and general practice

• Telemedicine: 'The use of telecommunication and information technology for the purposes of providing remote health assessments and ther-
apeutic interventions.' NHS England55
• Synchronous telemedicine: 'Real-­time, audio-­video and telephone communication that connects physicians and patients in different loca-
tions.' American Medical Association6
• Asynchronous telemedicine: Also known as the 'store-­and-­forward' technique. It allows data, including text and images from online services,
to be transmitted and interpreted later.6
• General practice: General practice is the first point of contact for patients to access healthcare services. It offers a range of services, including
consultations, prescriptions, treatments and management of long-­term conditions, referrals to specialists, and health promotion. A wide
range of practitioners work in general practice including doctors (GPs), nurses, and other allied health professionals.56

owing to poor implementation into existing clinical systems. Further research should investigate the
implementation, cost-­effectiveness, safety, and equity of asynchronous telemedicine use.

Introduction
Telemedicine, the use of telecommunication for providing remote health assessments and therapeutic
interventions, as defined in Box 1, has been used in health care for several years and there is a
global focus on its development, owing to the rapid increase in use following the COVID-­19 pandemic
outbreak.1 During the pandemic, 99% of general practices in the UK adopted remote consultation
platforms, which was a major change in practice and a move towards asynchronous telemedicine,
allowing data to be transmitted, stored, and interpreted later.2 However, it is unclear whether
asynchronous telemedicine allows healthcare professionals to provide quality care for patients
according to the domains of healthcare quality: safety, timeliness, effectiveness, efficiency, equity, and
patient-­centredness, as outlined in Figure 1.3
Increased policy directives for telemedicine include the NHS Long Term Plan, aiming for ‘digital
first’ primary care by 2023–2024 through the NHS App.4 The Welsh Government aims for remote
delivery of 35% of initial and 50% of follow-­up appointments.5
Asynchronous telemedicine occurs through secure messaging, such as texting and online
platforms, and can involve clinical decision-­making aids.6,7 Uses include: evaluating whether patients
need further consultations; and communication between patients and healthcare professionals, or
between multiple healthcare professionals.6 The focus of this review is consultations between patients
and healthcare professionals for medical advice.
Synchronous telemedicine, which includes video and telephone consultations, has been more
widely researched than asynchronous telemedicine.8–10 Existing reviews have focused on areas such
as sharing images for dermatology consultations, and specific types of secure messaging such as
emails.11,12 There is a recent rapid review on the value of asynchronous communication between
patients and physicians in primary care,13 but none focusing specifically on quality of care. A pre-­
pandemic review on uses of e-­consultations in primary care highlighted that research into effectiveness
and safety of asynchronous telemedicine is needed.14
Asynchronous telemedicine has potential to change service delivery in the UK and internationally
as 90% of NHS consultations occur in general practice,15 there are high levels of public interest in
access to GP appointments,16–18 and practice has changed following COVID-­19. Therefore, reviewing
this field is important. Results will be guided by the domains of healthcare quality, a widely accepted
model of healthcare quality,3 which will assist in identifying evidence gaps.

Aim and objectives

The aim of this review was to investigate uses and effectiveness of asynchronous telemedicine in
general practice. The specific objectives were to:
• identify types of asynchronous telemedicine used in general practice;
• assess how asynchronous telemedicine in general practice performs on each domain of health-
care quality;
• describe how asynchronous telemedicine use has changed since the COVID-­ 19 pandemic
outbreak in March 2020.

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Figure 1 Domains of healthcare quality3

Method
This study occurred between October 2022 and April 2023, and is reported according to the Preferred
Reporting Items for Systematic Reviews and Meta-­Analyses (PRISMA) guidelines.19

Search strategy
Following pilot searching, MEDLINE, CINAHL, Embase, and Scopus were searched. Search themes
included general practice, asynchronous telemedicine, uses, effectiveness, and safety (full details in
Supplementary Figure S1). Further relevant studies were identified from reference lists of included
reports.
Reports published between January 2015 and 31 November 2022 were searched to identify
literature published before and following the COVID-­19 pandemic outbreak in March 2020.

Study selection
Eligibility criteria, detailed in Table 1, were developed using Population, Intervention, Comparison,
Outcome (PICO) framework.20
One researcher (CL) screened search results against inclusion criteria and 10% were independently
screened for agreement (AP). One researcher (CL) screened full texts and queries were discussed
within the research team. Search results and inclusion decisions were recorded using EndNote (version
20).21

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Table 1 Inclusion and exclusion criteria

Inclusion Exclusion

Population Patients and staff who have used asynchronous Other areas of primary care: dentistry,
telemedicine in a general practice setting, optometry, community nursing, pharmacy.
including all healthcare professionals and other Secondary and tertiary care.
members of staff and consultations relating to
all patient groups, including adults, children,
and carers.

Intervention All methods of asynchronous telemedicine; for Synchronous telemedicine such as video
example, e-­consults, secure messaging, text appointments, telephone appointments.
consultations, eVisits, emails. Automated asynchronous telemedicine,
Interactions between patients and healthcare telemonitoring, interactions between two or
professionals seeking medical advice. more healthcare professionals.

Comparison Face-­to-­face consultations.

Synchronous telemedicine.
No comparison.
Before, and following the outbreak of the
COVID-­19 pandemic.

Outcomes Uses of asynchronous telemedicine.

Safety
• Adverse events, harm caused or medical
errors.
Timeliness
• Time to appointment.
Effectiveness
• Diagnosis made or resolution of problem.
• Treatments delivered, for example,
prescribed medication.
• Number of appointments arranged
and attended following asynchronous
consultation and the type of follow-­up.
Efficiency
• Effect on workflow for healthcare
professionals and patients, cost-­
effectiveness.
• Reduction or replacement of other types of
consultations.
Equitability
• Access for patients.
Patient-­centredness
• Perceptions of patients and healthcare
professionals.

Study design Empirical research: Healthcare policies.

Quantitative studies: comparative and Editorials and opinion pieces.
observational studies. Case studies.
Mixed-­methods studies. Study protocols.
Qualitative studies.
Other English language.
Studies including data from 2015 onwards.
Studies involving healthcare systems that are
comparable with the NHS, for example, OECD
countries.
OECD = Organization for Economic Cooperation and Development

Data extraction
CL carried out data extraction. A template was piloted and discussed within the research team. The
final template (Supplementary Figure S2) was based on this review’s objectives and assisted consistent
data extraction across studies, including the design, participant characteristics (staff or patients), type

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Figure 2 PRISMA flow diagram

of asynchronous telemedicine, and comparators. Also retrieved were each study’s objectives, patients
involved, main findings, and whether the results were before or following the COVID-­19 pandemic
outbreak.

Critical appraisal
Critical appraisal was at study level with the aid of the Mixed Methods Appraisal Tool (MMAT) for
qualitative, quantitative, and mixed-­methods studies.22 The Critical Appraisal Skills Programme (CASP)
checklist was also used for qualitative studies.23 There was no formal risk of bias due to heterogeneity
of included studies.

Data synthesis
A narrative synthesis approach was used.24 Results were grouped and synthesised according to the
study’s objectives and six domains of healthcare quality by one author (CL), and this was discussed
within the research team until agreement was reached.3
No meta-­analysis was carried out owing to inclusion of qualitative data.

Results
Search results
Database searching returned 9040 reports. After removing duplicates, 6864 remained; 6777 were
excluded through title and abstract screening, so 87 remained. Eighty-­ one were retrieved and
assessed for eligibility. Six were inaccessible. Eleven further records were retrieved through citation
searching; four were assessed for inclusion following title and abstract screening, and three of these
were excluded. Twenty-­seven reports from 23 primary studies were included.

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Table 2 Types of asynchronous communication reported

Online platforms (n = 21)

eConsult, UK26,31–33,40,45 Online questionnaire initiated by patients with responses via email, text,
or synchronous consultations (telephone or face-­to-­face).
Responses next working day.

eConsulta, Spain28,46,47 Two-­way online messaging between patient and clinician.

Consultations initiated by patients or healthcare professionals.

Zipnosis, US36,37 Patient questionnaire, including free-­text options, which is responded to

by a physician with the aid of a decision support algorithm.
Responses within 1 hour during business hours (8am–8pm).

Docly, UK42 Online questionnaire with included decision support algorithms and
responses from GPs via secure messaging within the portal.

Digital dialogue with the GP, Norway39 Electronic consultation with GPs through online portal.
Part of a wider online service that also offered non-­clinical services to
patients.

Other: secure messaging, websites, apps, eVisits or a mixture.

Email (n = 2)49,57

GPs give out personal or practice email address to patients.

Some managed by administrative staff, some by GPs.

Text messages (n = 3)29,43,57

GPs give out personal or practice phone number to patients.
Some managed by administrative staff, some by GPs.
Some of the studies report on more than one mode of asynchronous telemedicine.

Figure 2 summarises screening and Supplementary Table S2 details reasons for exclusion at full
text.

Study characteristics
Studies were from the UK (n = 9), the US (n = 5), Spain (n = 2), Sweden (n = 1), Switzerland (n = 1),
The Netherlands (n = 1), Republic of Ireland (n = 1), Norway (n = 1), Canada (n = 1), and Israel (n = 1).
Designs included the following (some studies used more than one design): interview studies (n =
8); cross-­sectional surveys (n = 8); free-­text responses (n = 3); cross-­sectional data (n = 2); qualitative
data (n = 2); and cohort studies (n = 10).
Three studies compared the COVID-­19 pandemic period with the period before the pandemic,25–28
and one addressed only the pandemic period.27
Supplementary Table S1 details study characteristics.

Types of asynchronous communication

Table 2 details asynchronous telemedicine types reported. This review focused on consultations for
medical advice, but other uses included prescriptions, sickness certification notes, and managing
appointments.

Staff use of asynchronous telemedicine

GPs, nurses, and administrative staff use asynchronous telemedicine. One study reported female GPs
were more likely to text patients,29 but one found no difference in use by healthcare professionals’
sex or age.30

Patient use of asynchronous telemedicine

Patients from a range of demographics were included, consulting for new and ongoing concerns.
Eighteen studies involved adult general practice patients. Six involved patients with predefined
conditions only.
Studies reported 57–79% of asynchronous consultations were completed by female patients. Six
reported patients who used asynchronous telemedicine were younger on average than users of face-­to-­

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face consultations,31–39 but use was reported across all age groups. Two studies found socioeconomic
factors had no effect on uptake,31–33,40 whereas others reported differences in use between religious
and ethnic groups,25 higher uptake from patients in rural areas,28,41 and higher uptake from patients
with higher education levels.39

Study quality
Studies had appropriate designs to address their aims. However, owing to many being observational,
non-­response bias was a limitation. This means their results cannot be assumed to be representative
of study populations, which is important to consider when interpreting the results of this review,
which offers a descriptive overview of existing evidence and suggests where gaps lie. More significant
limitations include omissions in methodology, such as overlooking confounders or reasons for missing
data. Qualitative studies lacked details of data saturation.
Supplementary Table S1 includes study specific comments and Supplementary Table S3 details
critical appraisals.

Domains of healthcare quality

Safety
Studies showed no differences between numbers of patients admitted to hospital or seeking
emergency care according to consultation type; however, safety outcomes are not widely reported.
One study found 55.6% of GPs in Ireland obtain specific consent when texting medically sensitive
information, 29.8% do sometimes, and 23.6% never do, raising consent and confidentiality concerns.29
To avoid receiving a ‘phone 999’ message when using eConsult, patients downplayed symptoms.26
It is unclear whether this problem with platform usability caused safety concerns. One example of a
safety concern was a patient requiring further medication at follow-­up; the authors inferred this meant
their condition could have worsened following asynchronous consultation.42

Timeliness
Most asynchronous platforms were available 24 hours, 7 days a week. Some had expected response
times, ranging from 15 minutes34,35 to 48 hours.43 Two studies found patients completing virtual
consultations reported shorter symptom durations before consultation than those who had face-­to-­
face consultations.36,37

Effectiveness
Diagnoses and investigations
One study found diagnoses were made based on symptoms following 25% of asynchronous
consultations, compared with 14.2% of face-­ face consultations.34,35 Face-­to-­face consultations
to-­
resulted in more investigations, but more inappropriate diagnoses.37
36

Prescriptions
One study found 58% of patients received a prescription following asynchronous consultation;44 for
example, antibiotics, birth control, and respiratory medications. Antibiotic prescriptions were in line
with guidelines more often following e-­consultations than face-­to-­face consultations and fewer were
prescribed following e-­consultations.34–37

Resolution of queries and further appointments

Patient reported resolution of queries occurred in 33–66% of cases following asynchronous
consultation. One study reported complete resolution more often following e-­consultations than face-­
to-­face consultations (55% versus 33%).45 Fewer patients felt able to provide all relevant information
during e-­consultation and resolution was not related to whether the consultation was initiated by the
patient or clinician.46,47 It is unclear whether clinicians felt queries were resolved and what reasons
existed for unresolved queries.
Follow-­up rates ranged from 25.8–66.1%. One study found mean follow-­up time was 1.2 days.44
Many were telephone or face-­ to-­
face, (55.3–74%), which were more likely when patients had

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new or complex problems,31–33 or required physical examination.34,35 Compliance with follow-­

up
recommendations varied; 17.6–87.5%.

Healthcare professionals’ confidence

Clinicians’ experience with asynchronous telemedicine could influence outcomes.31–33 One study found
GPs felt confident with 97% of requests received,45 but another reported some limited confidence.48

Efficiency
Comparison with other consultation types
E-­consultations were considered by GPs in one study as potentially being able to replace 55–88% of
face-­to-­face consultations.46,47 Timewise, they take between 2.5 and 10 minutes, so are equivalent to
telephone and face-­to-­face consultations.30,40
One study reported 21% of practices previously used electronic messaging but stopped; it is
unclear why.49

Effects on staff workflow

Six studies reported asynchronous telemedicine added to clinical and administrative workload,
through adding a stream of work and increasing demand, but it is unclear whether this is offset by
reductions in other consultations.
One study reported e-­consultations led to more screen time, less interaction with people but
promoted teamwork.48 Barriers to improved workflow included poor communication, information
flow, and usability of online systems.50 Positive effects were convenience for staff and saving time on
administrative tasks and other consultations.

Patient non-adherence to systems

Eight studies reported patient non-­adherence to asynchronous systems negatively affected workflow
and staff thought patients used them as a ‘shortcut’ to other consultations.

Costs
Costs or savings would be influenced by the efficiency of systems, as this determines whether other
consultation types have been replaced, potentially saving resources for practices and staff. An
economic evaluation of eConsult found no added costs, but they were unable to tell if savings were
made owing to low usage.40 Otherwise, costs were poorly reported.

Equity
Equity is not widely reported. Qualitative evidence suggested asynchronous telemedicine could
improve access to general practice for patients with hearing difficulties, and those who are housebound
or have caring responsibilities.29,48 Concerns included digitally excluded patients and reinforcing
health inequities.31–33,43,48

Patient-centredness
Eight studies reported benefits for patients, including convenience, as asynchronous consultations can
be completed out of hours and at home, saving an average of 1 hour in travel, waiting and consultation
time, and travel costs. Patients reported faster responses and improved quality of treatment.39 One
study reported asynchronous telemedicine promoted patient engagement and empowerment.50
Negative effects included increased responsibility for patients and laborious questionnaires.

Changes following COVID-19 pandemic outbreak

Studies reported low asynchronous telemedicine use before the pandemic; up to seven consultations
per 1000 patients per month.31–33,35 Three studies reported patient use of asynchronous telemedicine
increased gradually before the pandemic26,31–33,40 and in 2016 20% of UK general practices planned
to introduce it.49
Four studies reported use of asynchronous telemedicine increased rapidly following the COVID-­19
pandemic outbreak in March 2020.25,27,43,50 One study found 70.88% of users avoided face-­to-­face
primary care during the pandemic,30 with e-­consultation rates increasing from 5.61 per 1000 patients

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in March 2020 to 33.1 per 1000 patients in June 2020 in one healthcare system.28 Despite increased
use, only 32% of practices in The Netherlands intended to continue using e-­consultations.27
Average asynchronous telemedicine users during the pandemic were younger, more likely to be
employed. and had fewer chronic diseases than average users before the pandemic,28 and the gap
between numbers of female and male users increased.26
Table 3 provides a synthesis of results and the gaps in the evidence base identified in this review.

Discussion
Summary
Asynchronous telemedicine is used by a range of staff and patients worldwide. It can be effective in
making diagnoses, prescribing medications, and takes equivalent time to face-­to-­face and telephone
consultations. For patients, it can provide timely access to general practice and save on travel time and
costs. Hindrances to efficiency are reported, such as increased clinical and administrative workload
and barriers to workflow, such as poor usability. Safety and equity are poorly reported, but concerns
include consent, confidentiality, and reinforcing health inequalities. Its use increased rapidly following
the pandemic outbreak in March 2020.

Comparison with existing literature

A pre-­pandemic review of e-­consultations in primary care found similar patterns of patient use, including
more female users and use across all age groups. Mold and colleagues found socioeconomically
disadvantaged patients used e-­consultations less, which is inconsistent with our findings.14 However,
there is a lack of causative evidence for this, as our findings in this domain are from qualitative sources.
Consistencies with synchronous telemedicine include providing time and cost savings for
patients,51–53 and evidence suggesting a lack of guidance for use of both makes confidentiality a
concern.14,54 Synchronous telemedicine can provide cost savings for healthcare systems,11 but costs
are poorly reported for asynchronous telemedicine.
Mold et al found (i) patients were more likely to use e-­consultations if they thought a face-­to-­face
consultation was not needed, and (ii) no increased workload for clinicians, both of which findings
are inconsistent with our findings.14 These differences could be influenced by their review, including
synchronous and asynchronous telemedicine and being carried out before COVID-­19, or could be
owing to the qualitative nature of evidence found in our review.

Strengths and limitations

A limitation is that data extraction and synthesis were carried out by only one researcher. To minimise
this, both processes were discussed within the research team throughout, until agreement was
reached.
There was no formal risk of bias assessment owing to the heterogeneity of included studies.
However, studies were critically appraised using the MMAT and additionally CASP for qualitative
studies, which is a strength.
All included studies were observational or qualitative and many were on a small scale, which limits
the clinical significance of their results. Additionally, the heterogeneity between types of asynchronous
communication reported makes it difficult to compare studies. This limits how definitive the findings
of this review can be, which is why a narrative synthesis approach was chosen, allowing a descriptive
overview of the existing literature, and identification of significant evidence gaps.
A strength of this review is the use of the domains of healthcare quality,3 which are a globally
recognised framework, and allow for the finding to be applied to worldwide healthcare systems. This
is strengthened further by the inclusion of international literature.

Implications for research and practice

Policymakers should focus on how to address ethical issues, such as documenting consent and patient
information, to ensure awareness and manage expectations of asynchronous telemedicine in a safe
manner.
A standardised approach to asynchronous telemedicine in general practice, such as introducing
one platform, and defining enquiries it should be used for would improve practice and increase

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Table 3 Summary of results and evidence gaps according to study objectives

Objective Evidence Gaps

Identify types of asynchronous telemedicine used in • Online platforms are most used. Text • Unclear why implementation differed between
general practice. messages and email also used. practices.
• Implementation differed between • Unclear whether groups of healthcare staff
countries, platforms, and sometimes are more or less likely to use asynchronous
practices or individual clinicians. telemedicine.
• Used by a range of general practice staff. • Reasons for younger people and female
• Use reported across all patient patients using asynchronous telemedicine
demographics. Used more by females more than older people and male patients are
and younger people. needed.
• Unclear whether demographic factors, such as
religion, ethnic group, socioeconomic status,
and geographical location, affects use.
Assess how asynchronous Safety • No differences in numbers of • Not widely reported in included studies.
telemedicine in general patients admitted to hospital or • Studies using clear clinical end-­point safety
practice performs on each seeking emergency care according to measures are required.
domain of healthcare consultation type.
quality. • Concerns surrounding consent and
confidentiality.

Timeliness • Many platforms available 24 hours, 7 days • Response times often poorly reported.
a week, with clear response times up to
48 hours.
• Patients reported shorter symptom
duration before asynchronous
consultation.

Effectiveness • More accurate diagnoses made and • Unclear whether clinicians felt patient
fewer investigations. queries were resolved during asynchronous
• Range of prescriptions issued. consultation.
• Antibiotic prescriptions more often in line • Reasons for unresolved queries are unclear.
with guidelines. • Owing to range in reported follow-­up rates
• Patients reported resolution of queries (25.8%–66.1%) we cannot know if other
in many cases, but fewer felt able to consultation rates (face-­to-­face or telephone)
provide all relevant information. are being reduced.
• Many follow-­ups were face-­to-­face or
telephone.
• Many clinicians felt confident dealing
with asynchronous consultations.

Efficiency • Two studies reported asynchronous • Unclear what type of consultations can and
telemedicine could replace more than cannot be carried out asynchronously and
half of face-­to-­face consultations. reasons for this.
• They take equivalent length of time to • Contradictory reports of increased workflow
face-­to-­face and telephone consultations. but also time savings for clinical and
• Reports of additional workload for clinical administrative staff.
and administrative staff, but also reports • Unclear why there is a lack of usability and
of time savings. information flow, whether problems with the
• Barriers to improved workflow: poor platform or its implementation.
communication, lack of usability, and • Reasons for patient non-­adherence.
information flow. • Further economic evaluation is required.
• Patient non-­adherence negatively affects
workflow.
• One economic evaluation reported no
added cost but unable to tell whether
there are savings.

Equity • Qualitative evidence suggests improved • Not widely reported in included studies.
access for some groups. • Further studies are required to identify whether
• Concerns regarding digitally excluded specific groups are excluded and advantaged
patients and reinforcing existing health or disadvantaged by using asynchronous
inequities. telemedicine.
Patient-­centredness • Reports of benefits: convenience, savings • Patient involvement in design of platforms to
in travel time and costs, faster treatment. ensure usability clear.
• Increased engagement and
empowerment.
• Reports of questionnaires being
laborious.

continued on next page

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Table 3 Continued
Objective Evidence Gaps

Describe how asynchronous telemedicine use has • Huge increase in use of asynchronous • Unclear whether increased use has been
changed since the COVID-­19 pandemic outbreak in telemedicine from March 2020. maintained.
March 2020. • Allowed face-­to-­face consultations to be • Reasons for younger people and female
avoided. patients using asynchronous telemedicine
• Users were younger, employed, with more are needed.
fewer chronic conditions, and more
female patients.

sustainability. This is important in the NHS as UK-­based studies reported patient non-­adherence to
asynchronous systems.26,30–33,40,43,45
A standardised approach will be influenced by further research into the implementation of
asynchronous telemedicine in general practice. This is of importance as there were reports of practices
stopping using asynchronous telemedicine,27,49 problems with workflow, and increased workload
despite reports suggesting it can replace face-­to-­face consultations, which could all be influenced by
its implementation. Further, the COVID-­19 pandemic offered a unique opportunity for asynchronous
telemedicine to be studied as there was huge widespread implementation, and it is unclear whether
this has been maintained.
Future research should address the safety, economic costs, time savings, and whether specific
groups are advantaged or disadvantaged by using asynchronous telemedicine. This should be through
high quality large-­scale studies, such as randomised control trials and observational or cross-­sectional
studies, using clear clinical end-­point outcomes.
In conclusion, asynchronous telemedicine, such as online platforms, text, and email, is used in
general practice worldwide by many staff and patients. It can provide effective, efficient, and timely
care, and benefits for patients. Increased workload for staff and barriers to efficient workflow are
reported. The COVID-­19 pandemic led to rapid increases in asynchronous telemedicine use. Further
evaluation of cost-­effectiveness, equity, and safety of asynchronous telemedicine is required, and
studies of its implementation will inform future policy and enable sustainable practice.

Funding
This systematic review was carried out as part of CL's intercalated research project for an under-
graduate BSc in Population Medicine (Cardiff University School of Medicine). The views expressed
in the article submitted are those of the contributing authors and are not the official views of Cardiff
University School of Medicine or Division of Population Medicine.

Ethical approval
This study is a systematic review of the literature so there are no research elements that require
ethical approval.

Trial registration number

The protocol was registered with PROSPERO; registration number CRD42023394484.

Provenance
Freely submitted; externally peer reviewed.

Data
The dataset relied on in this article is fully avaliable in the results and supplementary materials.

Acknowledgements
Elizabeth Gillen (Information Specialist, Cardiff University School of Healthcare Sciences) for her
guidance in designing the search strategy for this review.

References
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