A mixed methods systematic review of the effects of patient online self-diagnosing in the ‘smart-phone society’ on the healthcare professional-patient relationship and medical authority

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

6109 titles were screened and 708 passed to abstract screening.

“6109 titles were screened and 708 passed to abstract screening.”

May combine two claims.

Accessibility and speed were key identified benefits of online self-diagnosing.

“Accessibility and speed were key identified benefits of online self-diagnosing.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The included studies were from the United Kingdom (5), United States (6), Canada (2), Austria (1), Israel (4), Australia (2), Switzerland (3), Portugal (1) and China (1).

“Five studies had taken place in the United Kingdom [27–31], six from the United States [32–37], two from Canada [38, 39], one from Austria [40], four from Israel [41–44], two from Australia [45, 46], three from Switzerland [47–49], one from Portugal [50] and one from China [51].”

May combine two claims.

The internet allows 24-h access, whereas obtaining an appointment with a HCP can be difficult.

“The internet allows 24-h access, whereas obtaining an appointment with a HCP can be difficult [30, 31, 34].”

• cites [30] Donnelly LS, Shaw RL, van den Akker OB. eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. J R Soc Med. 2008;101(10):501–6. sourceNot checked yet

  Not checked in the free run.

• cites [31] Stevenson FA, Kerr C, Murray E, Nazareth I. Information from the internet and the doctor-patient relationship: the patient perspective – a qualitative study. J BMC Family Pract. 2007;8(1):47. sourceNot checked yet

  Not checked in the free run.

• cites [34] Macias W, McMillan S. The return of the house call: The role of internet-based interactivity in bringing health information home to older adults. Health Commun. 2008;23(1):34–44. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Fewer studies explored the HCP's perspectives compared to the patient's perspectives.

“Fewer studies explored the HCP’s perspectives compared to the patient’s perspectives.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The internet allowed patients and the public to expand their knowledge and gain a deeper understanding of health information without involving their HCP.

“It allowed patients and the public to expand their knowledge and gain a deeper understanding of health information without involving their HCP.”

May combine two claims.

People in countries where patients pay for their healthcare reported online self-diagnosis to be money saving and time efficient.

“For example, people in countries where patients pay for their healthcare reported online self-diagnosis to be money saving and time efficient; they could access health information with ease for free as opposed to waiting for a healthcare appointment and then having to pay a fee [37].”

• cites [37] Fiksdal AS, Kumbamu A, Jadhav AS, Cocos C, Nelsen LA, Pathak J, et al. Evaluating the process of online health information searching: a qualitative approach to exploring consumer perspectives. J Med Internet Res. 2014;16(10):e224–e. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Database searches retrieved 7026 papers in total, which reduced to 6109 after deduplication.

“Database searches retrieved 7026 papers in total which reduced to 6109 after deduplication.”

Classified as probably not a substantial claim. May combine two claims.

The four main themes are: 1) patient perspectives on using the internet to seek health information; 2) healthcare professionals' perspectives on and reactions to internet-informed patients; 3) sharing online health information with healthcare professionals; 4) impact of online medical searches and diagnosis on patient-healthcare professional relationships.

“The four main themes are: 1) patient perspectives on using the internet to seek health information; 2) healthcare professionals’ perspectives on and reactions to internet-informed patients; 3) sharing online health information with healthcare professionals; 4) impact of online medical searches and diagnosis on patient-healthcare professional relationships”

May combine two claims.

Patients found the internet convenient and that it allowed them to become more self-aware and to share their experiences within online health forums.

“Patients found the internet convenient and that it allowed them to become more self-aware and to share their experiences within online health forums [33].”

• cites [33] Rupert DJ, Moultrie RR, Read JG, Amoozegar JB, Bornkessel AS, O’Donoghue AC, et al. Perceived healthcare provider reactions to patient and caregiver use of online health communities. J Patient Educ Couns. 2014;96(3):320–6. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The internet was seen as beneficial to revisit the information as many times as required for free.

“It was also seen as beneficial to revisit the information as many times as required for free [33].”

• cites [33] Rupert DJ, Moultrie RR, Read JG, Amoozegar JB, Bornkessel AS, O’Donoghue AC, et al. Perceived healthcare provider reactions to patient and caregiver use of online health communities. J Patient Educ Couns. 2014;96(3):320–6. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

All 25 included studies presented clear research questions and collected data to address the questions.

“All 25 studies presented clear research questions and collected data to address the questions.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

708 abstracts were screened and 289 were assessed for full text screening.

“708 abstracts were screened and 289 were assessed for full text screening.”

May combine two claims.

Most quantitative studies used appropriate statistical analysis and appropriate measurements.

“Most quantitative studies used appropriate statistical analysis to answer the research questions and used appropriate measurements.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Four major themes and several subthemes were identified from the synthesis of the literature.

“Four major themes and several subthemes were identified from the synthesis of the literature.”

May combine two claims.

Contradictory information could result in additional questions arising about health and trigger a seemingly endless cycle of information seeking.

“Contradictory information could result in additional questions arising about health and trigger a seemingly endless cycle of information seeking [38, 39].”

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

• cites [39] Silver MP. Patient perspectives on online health information and communication with doctors: a qualitative study of patients 50 years old and over. J Medical Internet Res. 2015;17(1):e19. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Almost all quantitative studies had pre-tested and piloted surveys before use.

“Almost all the quantitative studies had pre-tested and piloted surveys before use.”

May combine two claims.

Most qualitative studies used appropriate data collection methods, reported findings adequately derived from the data, and provided coherence between qualitative data sources, collection, analysis and interpretation.

“Most of the qualitative studies used appropriate data collection methods to answer the research questions, reported the findings adequately derived from the data and provided coherence between qualitative data sources, collection, analysis and interpretation.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Studies more frequently included middle-aged females and those of 'white' ethnicity.

“Although studies more frequently included middle-aged females and those of ‘white’ ethnicity.”

May combine two claims.

The internet was thought to be informative, but there was evidence that people had concerns about the quality of information available on the internet, with the belief it could be contradictory at times and should be seen as provisional.

“Essentially, the internet was thought to be informative, but there was evidence that people had concerns about the quality of the information available on the internet, with the belief it could be contradictory at times and should be seen as provisional [38].”

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Of the 25 eligible papers, there were 16 qualitative, 8 quantitative and 1 mixed method study.

“Of the 25 eligible papers, there were 16 qualitative, 8 quantitative and 1 mixed method study.”

• Also stated in: § Results · plain

  “Of 6107 records identified, 25 articles met the review eligibility criteria which included 16 qualitative, 8 quantitative and 1 mixed method study.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The final number of papers deemed eligible from the database search was 23.

“The final number of papers deemed eligible to be included from the database search, was 23.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Backward and forward chaining discovered another two papers meeting eligibility criteria, making the final number of included papers 25.

“During this process, another two papers were discovered to meet the eligibility criteria for review, making the final number of included papers in this mixed methods systematic review, 25”

Probably not a substantial claim: may not pass S3 (load-bearing).

The sample sizes of included studies ranged from 11 to 975.

“The sample sizes ranged from 11 to 975 with participants including patients either posting online or attending primary care clinics, carers, physicians such as GP’s, nurses and various other HCP’s.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The internet was generally seen as a tool for the treatment of non-serious medical issues or for self-diagnosis.

“The internet was generally seen as a tool for the treatment of non-serious medical issues or for self-diagnosis [40].”

• cites [40] Haluza D, Naszay M, Stockinger A, Jungwirth D. Digital natives versus digital immigrants: influence of online health information seeking on the doctor–patient relationship. J Health Commun. 2017;32(11):1342–9. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Some people saw online self-diagnosis as a method to increase their knowledge, making them better prepared and equipped for health consultations.

“Some people saw online self-diagnosis as a method to increase their knowledge, making them better prepared and equipped for health consultations.”

May combine two claims.

Some health knowledge acquired online was beyond the expertise of GPs, causing patients to feel the need to perform research themselves to improve their self-care.

“It was also reported that some health knowledge acquired online, was beyond the expertise of General Practitioners (GPs), causing patients to feel the need to perform research themselves to improve their self-care [31].”

• cites [31] Stevenson FA, Kerr C, Murray E, Nazareth I. Information from the internet and the doctor-patient relationship: the patient perspective – a qualitative study. J BMC Family Pract. 2007;8(1):47. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Having a better understanding of symptoms and conditions was thought to help patients engage more effectively with HCPs.

“Having a better understanding of symptoms and conditions was thought to help them to engage more effectively with HCP’s.”

May combine two claims.

Difficulties included information overload and complex or contradictory information.

“Difficulties included information overload and complex or contradictory information [47].”

• cites [47] Sommerhalder K, Abraham A, Zufferey MC, Barth J, Abel T. Internet information and medical consultations: experiences from patients’ and physicians’ perspectives. Patient Educ Couns. 2009;77(2):266–71. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Patients tended to present information to the healthcare professional to support the therapeutic relationship rather than to challenge it and to become more involved in the decision-making process of their healthcare.

“Patients tended to present information to the healthcare professional to support the therapeutic relationship rather than to challenge it and to become more involved in the decision-making process of their healthcare.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Online self-diagnosis was seen as a way to help patients make the most of the short time in consultations so they know what questions to ask.

“It was also seen as a way to help them to make the most of the short time they have in consultations so they know what questions to ask [30, 38].”

• cites [30] Donnelly LS, Shaw RL, van den Akker OB. eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. J R Soc Med. 2008;101(10):501–6. sourceNot checked yet

  Not checked in the free run.

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

This impacts patients' ability to depend on information and causes the public to find the internet less reliable than other sources of information such as HCPs.

“This impacts patients’ ability to depend on information and causes the public to find the internet less reliable than other sources of information such as HCPs [50].”

• cites [50] Mendes Á, Abreu L, Vilar-Correia MR, Borlido-Santos J. “That should be left to doctors, That’s what they are there for!”—exploring the reflexivity and Trust of Young Adults When Seeking Health Information. Health Commun. 2017;32(9):1076–81. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

People feel responsible for their own health and find the internet to be a source that provides information rapidly with accessibility at their convenience.

“People feel responsible for their own health and find the internet to be a source that provides information rapidly with accessibility at their convenience.”

May combine two claims.

Most healthcare professionals agreed on the importance of collaboration with patients and the need to develop a partnership and shared decision-making process but struggled to find time in the consultation to do so efficiently.

“Most healthcare professionals agreed on the importance of collaboration with patients and the need to develop a partnership and shared decision-making process but struggled to find time in the consultation to do so efficiently.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The internet was seen to work well as a means for self-diagnosis or to find information to help ease patients' minds while awaiting doctors' appointments.

“The internet was seen to work well as a means for self-diagnosis or to find information to help ease patients’ minds while awaiting doctors’ appointments [30].”

• cites [30] Donnelly LS, Shaw RL, van den Akker OB. eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. J R Soc Med. 2008;101(10):501–6. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Some healthcare professionals felt that the internet was advantageous for patients looking after their own health, while others felt it was due to a lack of trust in their expertise.

“Some healthcare professionals felt that the internet was advantageous for patients looking after their own health, while others felt it was due to a lack of trust in their expertise.”

Probably not a substantial claim: may not pass S3 (load-bearing).

HCPs were viewed as expert guides who could aid navigation through the otherwise overwhelming quantities of health-related internet information.

“HCP’s were thus viewed as expert guides who could aid navigation through the otherwise overwhelming quantities of health-related internet information [38].”

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Several patients did not want to tread on the HCP's toes; they perceived they would be challenging the professional and did not want to question them or make them feel offended or intimidated by attempts to discuss online health information, thus interrupting the diagnostic process.

“Several patients did not want to tread on the HCP’s toes; such patients perceived they would be challenging the professional and did not want to question them or make them feel offended or intimidated by attempts to discuss online health information, thus interrupting the diagnostic process [27, 32, 47].”

• cites [27] Bowes P, Stevenson F, Ahluwalia S, Murray E. ‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations. J Gen Pract. 2012;62(604):e732–e8. sourceNot checked yet

  Not checked in the free run.

• cites [32] Imes RS, Bylund CL, Sabee CM, Routsong TR, Sanford AA. Patients’ reasons for refraining from discussing internet health information with their healthcare providers. J Health Commun. 2008;23(6):538–47. sourceNot checked yet

  Not checked in the free run.

• cites [47] Sommerhalder K, Abraham A, Zufferey MC, Barth J, Abel T. Internet information and medical consultations: experiences from patients’ and physicians’ perspectives. Patient Educ Couns. 2009;77(2):266–71. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

HCPs sometimes experience anxiety around internet-informed patients, and some may find information patients bring to consultations slightly outside their area of expertise.

“HCP’s do sometimes experience anxiety around internet-informed patients, and some may find some of the information patients bring to consultations, slightly outside their area of expertise [38].”

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

There is a known fear among HCPs of losing control of the consultation with internet-informed patients and of being perceived as incompetent.

“There is also a known fear of losing control of the consultation with internet-informed patients and the feeling of being perceived as incompetent [28].”

• cites [28] Ahluwalia S, Murray E, Stevenson F, Kerr C, Burns J. ‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to a consultation. Br J Gen Pract. 2010;60(571):88–94. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Other reasons for patients not discussing online health information research included feeling embarrassed and not wanting to be seen negatively.

“Other reasons for patients not discussing online health information research included feeling embarrassed and not wanting to be seen negatively [27, 32, 39]”

• cites [27] Bowes P, Stevenson F, Ahluwalia S, Murray E. ‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations. J Gen Pract. 2012;62(604):e732–e8. sourceNot checked yet

  Not checked in the free run.

• cites [32] Imes RS, Bylund CL, Sabee CM, Routsong TR, Sanford AA. Patients’ reasons for refraining from discussing internet health information with their healthcare providers. J Health Commun. 2008;23(6):538–47. sourceNot checked yet

  Not checked in the free run.

• cites [39] Silver MP. Patient perspectives on online health information and communication with doctors: a qualitative study of patients 50 years old and over. J Medical Internet Res. 2015;17(1):e19. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

HCPs agreed on the importance of collaboration with and guidance for patients, though they struggled to find the time to do this efficiently.

“HCP’s agreed on the importance of collaboration with and guidance for patients, though they struggled to find the time to do this efficiently [38].”

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some HCPs believed patients should take responsibility for their own health and be able to make decisions, provided they can base these decisions on high-quality sources of information.

“They also believed patients should take responsibility for their own health and be able to make decisions, provided that they can base these decisions on high-quality sources of information [48].”

• cites [48] Caiata-Zufferey M, Schulz PJ. Physicians’ communicative strategies in interacting with internet-informed patients: results from a qualitative study. Health Commun. 2012;27(8):738–49. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some HCPs felt that patients have a right to stay well-informed and that they are more satisfied this way.

“Some HCP’s felt that patients have a right to stay well-informed and that they are more satisfied this way.”

May combine two claims.

Such patients were concerned about HCPs' reactions to their health research online and felt that they might not be listened to or that professionals might become dismissive or uninterested.

“such patients were concerned about HCP’s reactions to their health research online and felt that they might not be listened to or that the professionals might become dismissive or uninterested [27, 32, 36, 39].”

• cites [27] Bowes P, Stevenson F, Ahluwalia S, Murray E. ‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations. J Gen Pract. 2012;62(604):e732–e8. sourceNot checked yet

  Not checked in the free run.

• cites [32] Imes RS, Bylund CL, Sabee CM, Routsong TR, Sanford AA. Patients’ reasons for refraining from discussing internet health information with their healthcare providers. J Health Commun. 2008;23(6):538–47. sourceNot checked yet

  Not checked in the free run.

• cites [36] Hay MC, Strathmann C, Lieber E, Wick K, Giesser B. Why Patients Go Online: Multiple Sclerosis, the Internet, and Physician-Patient Communication. Neurologist. 2008;14(6):374–81. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Several HCPs believed that the internet poses risks as patients may misinterpret information and this can cause unnecessary medical visits.

“Several HCP’s also believed that the internet poses risks as patients may misinterpret information and this can also cause unnecessary medical visits [28, 48].”

• cites [28] Ahluwalia S, Murray E, Stevenson F, Kerr C, Burns J. ‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to a consultation. Br J Gen Pract. 2010;60(571):88–94. sourceNot checked yet

  Not checked in the free run.

• cites [48] Caiata-Zufferey M, Schulz PJ. Physicians’ communicative strategies in interacting with internet-informed patients: results from a qualitative study. Health Commun. 2012;27(8):738–49. sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

It can become difficult for HCPs to do their jobs efficiently as they may need to explain, interpret or suggest a conflicting opinion to information presented from online resources.

“It can become difficult for HCP’s to do their jobs efficiently as they may need to explain, interpret or suggest a conflicting opinion to the information presented from online resources [48].”

• cites [48] Caiata-Zufferey M, Schulz PJ. Physicians’ communicative strategies in interacting with internet-informed patients: results from a qualitative study. Health Commun. 2012;27(8):738–49. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Many HCPs agreed that it was important to show support to patients who used the internet for health information, but that such behaviours can bring associated tensions.

“Many HCP’s agreed that it was important to show support to patients who used the internet for health information, but that such behaviours can bring associated tensions [38].”

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Internet-informed patients were considered by some HCPs as potentially preventing a physician from being as effective as they could be.

“Internet-informed patients were also considered by some as potentially preventing a physician from being as effective as they could be.”

May combine two claims.

Patients/public found adopted reactions from HCPs such as open body language and asking open questions, making the environment more comfortable and allowing them to feel more listened to, encouraging.

“Patients/public found adopted reactions from HCP’s such as open body language and asking open questions, making the environment more comfortable and allowing them to feel more listened to, encouraging [28].”

• cites [28] Ahluwalia S, Murray E, Stevenson F, Kerr C, Burns J. ‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to a consultation. Br J Gen Pract. 2010;60(571):88–94. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

77.9% of respondents were interested in their HCP referring them to appropriate online health websites.

“although 77.9% were interested in their HCP referring them to appropriate online health websites.”

• cites [41] Russ H, Giveon SM, Granek Catarivas M, Yaphe J. The effect of the internet on the patient-doctor relationship from the patient’s perspective: a survey from primary care. J IMAJ-Israel Med Assoc J. 2011;13(4):220.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Doctors' body language was extremely important and even a simple smile could change the dynamic of the conversation.

“They found that doctors’ body language was extremely important and that even a simple smile could change the dynamic of the conversation.”

May combine two claims.

Many patients did not use the internet to replace HCPs but rather to gain a deeper understanding of their symptoms or disease and to become more familiar with the appropriate terminology.

“However, many patients did not use the internet to replace HCP’s but rather to gain a deeper understanding of their symptoms or disease and to become more familiar with the appropriate terminology [36].”

• cites [36] Hay MC, Strathmann C, Lieber E, Wick K, Giesser B. Why Patients Go Online: Multiple Sclerosis, the Internet, and Physician-Patient Communication. Neurologist. 2008;14(6):374–81. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Patients felt more trust in HCPs and hoped for discussion regarding internet health information while seeking doctors' opinions.

“Patients felt more trust in HCP’s and hoped for discussion regarding internet health information while seeking doctors’ opinions [27].”

• cites [27] Bowes P, Stevenson F, Ahluwalia S, Murray E. ‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations. J Gen Pract. 2012;62(604):e732–e8. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Physicians' new role can be described as acting as a partner to the patient, who is now more involved in both medical decision-making and consultation.

“Their new role can be described as acting as a partner to the patient, who is now more involved in both medical decision-making and consultation [47].”

• cites [47] Sommerhalder K, Abraham A, Zufferey MC, Barth J, Abel T. Internet information and medical consultations: experiences from patients’ and physicians’ perspectives. Patient Educ Couns. 2009;77(2):266–71. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Most studies emphasised that, regardless of the popularity of online self-diagnosis, the majority of respondents valued HCPs' opinions more, understood their explanations of diagnoses better, and had more trust in them.

“Most studies emphasised that, regardless of the popularity of online self-diagnosis, the majority of respondents valued HCP’s opinions more, understood their explanations of diagnoses better, and had more trust in them [30, 50].”

• cites [30] Donnelly LS, Shaw RL, van den Akker OB. eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. J R Soc Med. 2008;101(10):501–6. sourceNot checked yet

  Not checked in the free run.

• cites [50] Mendes Á, Abreu L, Vilar-Correia MR, Borlido-Santos J. “That should be left to doctors, That’s what they are there for!”—exploring the reflexivity and Trust of Young Adults When Seeking Health Information. Health Commun. 2017;32(9):1076–81. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Some patients felt that sharing health information they found online with their HCPs could show that they had invested time and energy into the consultation; these respondents hoped this would promote them and their problems being taken more seriously.

“In contrast to these perceptions of negative reactions, some patients felt that sharing health information they found online with their HCP’s could show that they had invested time and energy into the consultation; these respondents hoped this would promote them and their problems being taken more seriously [27, 45].”

• cites [27] Bowes P, Stevenson F, Ahluwalia S, Murray E. ‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations. J Gen Pract. 2012;62(604):e732–e8. sourceNot checked yet

  Not checked in the free run.

• cites [45] Benetoli A, Chen T, Aslani P. How patients’ use of social media impacts their interactions with healthcare professionals. J Patient education counseling. 2018;101(3):439–44. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Where the HCP's response to health information seeking is negative and disrespectful, this can seriously impact the patient-HCP relationship, and in some cases, this can lead to a patient changing their doctor or practice.

“However, where the HCP’s response to health information seeking is negative and disrespectful, this can seriously impact the patient-HCP relationship, and in some cases, this can lead to a patient changing their doctor or practice [27].”

• cites [27] Bowes P, Stevenson F, Ahluwalia S, Murray E. ‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations. J Gen Pract. 2012;62(604):e732–e8. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Positive experiences of patients sharing online health information with their doctors include all occasions when the doctor listens, acknowledges, and offers further discussion about such information.

“Positive experiences of patients sharing online health information with their doctors include all occasions when the doctor listens, acknowledges, and offers further discussion about such information [33].”

• cites [33] Rupert DJ, Moultrie RR, Read JG, Amoozegar JB, Bornkessel AS, O’Donoghue AC, et al. Perceived healthcare provider reactions to patient and caregiver use of online health communities. J Patient Educ Couns. 2014;96(3):320–6. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Patients expected feedback on the validity of their research and recommendations for online health communities, allowing for more engagement in the decision-making process by the patient in conjunction with the HCP.

“They expected feedback on the validity of their research and recommendations for online health communities, allowing for more engagement in the decision-making process by the patient in conjunction with the HCP.”

May combine two claims.

Patients felt they had a better relationship with their HCP when they were able to discuss their online research with them and when their HCP responded positively to this.

“It was clear from the findings that patients felt they had a better relationship with their HCP when they were able to discuss their online research with them and when their HCP responded positively to this.”

May combine two claims.

Very few studies (2/25) included the nurse's perceptions of patients' online self-diagnosis and online health research, with most focusing on doctors.

“Very few studies (2/25) included the nurse’s perceptions of patients’ online self-diagnosis and online health research [42, 44]. with most focusing on doctors.”

• cites [42] Barnoy S, Volfin-Pruss D, Ehrenfeld M, Kushnir T. Self-epistemic authority and nurses’ reactions to medical information that is retrieved from Internet sites of different credibility. Nurs Health Sci. 2011;13(3):366–70. sourceNot checked yet

  Not checked in the free run.

• cites [44] Barnoy S, Volfin-Pruss D, Ehrenfeld M, Kushnir T. Factors affecting nurses’ attitudes in Israel toward patients who present them with internet medical information. Nurs Outlook. 2008;56(6):314–21. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Some physicians felt that it was good that patients were looking after their own health, whereas others felt they were being challenged with information found online and that their patient had lost trust in them when they turned to the internet for help.

“Some physicians felt that it was good that patients were looking after their own health, whereas others felt they were being challenged with information found online and that their patient had lost trust in them when they turned to the internet for help.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some HCPs thought online health information could cause anxiety among patients - especially when the information was misinterpreted, and this could lead to unnecessary medical visits.

“Some also thought it could cause anxiety among patients – especially when the information was misinterpreted, and this could lead to unnecessary medical visits [28, 48].”

• cites [28] Ahluwalia S, Murray E, Stevenson F, Kerr C, Burns J. ‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to a consultation. Br J Gen Pract. 2010;60(571):88–94. sourceNot checked yet

  Not checked in the free run.

• cites [48] Caiata-Zufferey M, Schulz PJ. Physicians’ communicative strategies in interacting with internet-informed patients: results from a qualitative study. Health Commun. 2012;27(8):738–49. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The internet is not seen as a replacement for visiting a HCP, but as offering a complimentary source of information.

“The internet is not seen as a replacement for visiting a HCP, but as offering a complimentary source of information [30, 50, 51].”

• cites [30] Donnelly LS, Shaw RL, van den Akker OB. eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. J R Soc Med. 2008;101(10):501–6. sourceNot checked yet

  Not checked in the free run.

• cites [50] Mendes Á, Abreu L, Vilar-Correia MR, Borlido-Santos J. “That should be left to doctors, That’s what they are there for!”—exploring the reflexivity and Trust of Young Adults When Seeking Health Information. Health Commun. 2017;32(9):1076–81. sourceNot checked yet

  Not checked in the free run.

• cites [51] Chu JT, Wang MP, Shen C, Viswanath K, Lam TH, Chan SSC. How, When and Why People Seek Health Information Online: Qualitative Study in Hong Kong. Interactive J Med Res. 2017;6(2):e24–e. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Online resources were viewed as valuable sources of emotional support and helpful resources to inform self-management and self-diagnosis of symptoms or conditions.

“Online resources were also viewed as valuable sources of emotional support and helpful resources to inform self-management and self-diagnosis of symptoms or conditions.”

May combine two claims.

People used information from the internet to become better informed about their health, to prepare for their consultation, to enable them to ask better questions and to help them better understand the information given to them by HCPs, thus helping to make consultations more productive for them.

“People used information from the internet to become better informed about their health, to prepare for their consultation, to enable them to ask better questions and to help them better understand the information given to them by HCP’s [30, 38] thus helping to make consultations more productive for them.”

• cites [30] Donnelly LS, Shaw RL, van den Akker OB. eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. J R Soc Med. 2008;101(10):501–6. sourceNot checked yet

  Not checked in the free run.

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The public still tend to trust the advice from a HCP over any other information source and trust in HCPs remained high.

“the public still tend to trust the advice from a HCP over any other information source and trust in HCP’s remained high.”

Probably not a substantial claim: may not pass S3 (load-bearing).

One study in this review focused solely on multiple sclerosis patients.

“One study in this review focused solely on multiple sclerosis patients [36].”

• cites [36] Hay MC, Strathmann C, Lieber E, Wick K, Giesser B. Why Patients Go Online: Multiple Sclerosis, the Internet, and Physician-Patient Communication. Neurologist. 2008;14(6):374–81. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

HCPs' reactions to people who had obtained health-related information from the internet were mixed; however, they were mostly positive.

“HCP’s reactions to people who had obtained health-related information from the internet were mixed; however, they were mostly positive.”

May combine two claims.

Patients found HCPs to be the most valued source of health information but found the internet to be a useful complementary tool.

“Patients found HCP’s to be the most valued source of health information but found the internet to be a useful complementary tool [30, 36, 47, 49, 50].”

• cites [30] Donnelly LS, Shaw RL, van den Akker OB. eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. J R Soc Med. 2008;101(10):501–6. sourceNot checked yet

  Not checked in the free run.

• cites [36] Hay MC, Strathmann C, Lieber E, Wick K, Giesser B. Why Patients Go Online: Multiple Sclerosis, the Internet, and Physician-Patient Communication. Neurologist. 2008;14(6):374–81. sourceNot checked yet

  Not checked in the free run.

• cites [47] Sommerhalder K, Abraham A, Zufferey MC, Barth J, Abel T. Internet information and medical consultations: experiences from patients’ and physicians’ perspectives. Patient Educ Couns. 2009;77(2):266–71. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The rising use of smartphones and rapidly increasing availability of health information on the internet has led to more people using the internet as their first healthcare resource, often before seeking professional advice.

“The rising use of smartphones [3] and rapidly increasing availability of health information on the internet has led to more people using the internet as their first healthcare resource, often before seeking professional advice [4].”

• cites [3] Carbonell X, Chamarro A, Oberst U, Rodrigo B, Prades M. Problematic use of the internet and smartphones in university students: 2006–2017. J Int J Enviro Research Public Health. 2018;15(3):475. sourceNot checked yet

  Not checked in the free run.

• cites [4] Gualtieri LN. The doctor as the second opinion and the internet as the first. CHI'09 Extended Abstracts on Human Factors in Computing Systems: ACM; 2009. sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

The date range 2007 to April 2018 was chosen to align with the launch of the first Apple iPhone in 2007.

“Therefore, this date range was chosen to bring the results in line with the launch of the first Apple smartphone, ‘Apple iPhone’ in 2007 [15].”

• cites [15] PROSPERO. International prospective register of systematic reviews 2018 [Available from: https://www.crd.york.ac.uk/prospero/.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

All full papers were screened independently by two reviewers (AF, BJ or FM).

“All full papers were screened independently by two reviewers (AF, BJ or FM).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The protocol for this review is registered on PROSPERO (CRD42018084230).

“The protocol is registered on PROSPERO [15], the International Prospective Register of Systematic Reviews (CRD42018084230).”

• cites [15] PROSPERO. International prospective register of systematic reviews 2018 [Available from: https://www.crd.york.ac.uk/prospero/.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The main concern reported by GPs in the 2015 UK survey was that online self-diagnoses would lead to increased appointment-making by the 'worried well'.

“The main concern reported by GPs in this survey was that online self-diagnoses would lead to increased appointment-making by the ‘worried well’.”

• cites [6] MDDUS. Data explosion leading to more “worried well”. Glasgow; 2015. Available from: http://www.mddus.com/news/news-digest/2015/january/data-explosion-leading-to-more-worried-well/.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

A standardised data extraction form adapted from Johnston et al. was used to collect study characteristics.

“A standardised data extraction form adapted from Johnston et al. [19] was used to collect study characteristics for papers that met the eligibility criteria”

• cites [19] Johnston B, McGill M, Milligan S, McElroy D, Foster C, Kearney N. Self care and end of life care in advanced cancer: literature review. J Eur J Oncol Nurs. 2009;13(5):386–98. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

This mixed method systematic review was developed in accordance with PRISMA quality requirements.

“This mixed method systematic review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) quality requirements [14].”

• cites [14] Moher D, Liberati A, Tetzlaff J, Altman DG, The PG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(7):e1000097. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

By 2013, more than one-third of US adults were searching online for medical information for self-diagnosis.

“A US survey reported that by 2013, more than one-third of US adults were searching online for medical information for self-diagnosis [5].”

• cites [5] Castillo M. More than one third of U.S. adults use internet to diagnose medical condition. New York: CBS News; 2013. Available from: https://www.cbsnews.com/news/more-than-one-third-of-us-adults-use-internet-to-diagnose-medical-condition/.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Title and abstracts were screened by one researcher (AF).

“Title and abstracts were screened by one researcher (AF).”

May combine two claims.

The patient-HCP relationship has been known to influence health outcomes and can improve the patient experience in the healthcare system.

“The patient-HCP relationship has been known to influence health outcomes and can improve the patient experience in the healthcare system [12, 13]”

• cites [12] Sabater-Galindo M, Fernandez-Llimos F, Sabater-Hernandez D, Martinez-Martinez F, Benrimoj SI. Healthcare professional-patient relationships: systematic review of theoretical models from a community pharmacy perspective. J Patient Educ Couns. 2016;99(3):339–47. sourceNot checked yet

  Not checked in the free run.

• cites [13] Fox S, Chesla C. Living with chronic illness: A phenomenological study of the health effects of the patient–provider relationship. J Am Acad Nurse Pract. 2008;20(3):109–17. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Concerns have been raised from within the nursing profession that some information accessed by people online may be of poor quality and may represent commercial interests of website owners rather than robust clinical evidence.

“Concerns have also been raised from within the nursing profession that some of the information being accessed by people may be of poor quality, and instead of being based on robust clinical evidence, merely represents the commercial interests of the website owners [8].”

• cites [8] Warner J. Too much information can be dangerous, not empowering. Nurs Times. 2011;107(35):13.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

In the same 2015 UK-wide survey, 21% of GPs had experienced people presenting with information they found online.

“and, 21% have experienced people presenting with the information they have found online [6].”

• cites [6] MDDUS. Data explosion leading to more “worried well”. Glasgow; 2015. Available from: http://www.mddus.com/news/news-digest/2015/january/data-explosion-leading-to-more-worried-well/.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

It has been suggested that doctors may feel intimidated by online self-diagnosis.

“It has also been suggested that doctors may feel intimidated by online self-diagnosis [7].”

• cites [7] McArdle H. ‘Doctors “should not be intimidated” by patients self-diagnosing online. Scotland: Herald; 2015.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

NPT has been successfully used in other systematic reviews.

“and has been successfully used in other systematic reviews [25, 26]”

• cites [25] Mair FS, May C, O'Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bull World Health Organ. 2012;90(5):357–64. sourceNot checked yet

  Not checked in the free run.

• cites [26] O’Connor S, Hanlon P, O’Donnell CA, Garcia S, Glanville J, Mair FS. Understanding factors affecting patient and public engagement and recruitment to digital health interventions: a systematic review of qualitative studies. BMC Med Informatics Decision Making. 2016;16(1):120. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Two reviewers (AF, BJ) independently assessed the quality of the eligible studies.

“Two reviewers (AF, BJ) independently assessed the quality of the eligible studies for reliability purposes.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Any data that fell outside the NPT framework was noted to ensure there was no 'shoe-horning' of themes into the framework.

“Any data that fell outside the framework was noted to ensure there was no “shoe-horning” of themes into the framework.”

Classified as probably not a substantial claim.

NPT is a useful framework to explain and understand how people integrate new interventions into their everyday routines.

“NPT is a useful framework to explain and understand how people integrate new interventions into their everyday routines [24].”

• cites [24] May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, et al. Using normalization process theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci. 2018;13(1):80. sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

The mixed methods appraisal tool (MMAT) was chosen because it is designed specifically for mixed method studies and appraises qualitative, quantitative, mixed methods, and other types of empirical studies.

“The mixed methods appraisal tool (MMAT) [20] was chosen because it is designed specifically for mixed method studies and appraises qualitative, quantitative, mixed methods, and other types of empirical studies [21]”

• cites [20] Pluye P, Gagnon M-P, Griffiths F, Johnson-Lafleur J. A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in mixed studies reviews. J Int J Nurs Studies. 2009;46(4):529–46. sourceNot checked yet

  Not checked in the free run.

• cites [21] Hong QN, PLUYE P, FÀBREGUES S, BARTLETT G, BOARDMAN F, CARGO M, et al. Mixed methods appraisal tool (MMAT), version 2018. 2018.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Each item of extracted data was coded independently through thematic analysis by researcher AF, and reviewed by two researchers (BJ, FM).

“Each item of extracted data was coded independently through thematic analysis by researcher AF, and reviewed by two researchers (BJ, FM).”

Classified as probably not a substantial claim.

All articles that met the study inclusion criteria were kept even if they were found to be methodologically weak based on the quality assessment.

“All articles that met the study inclusion criteria were kept even if they were found to be methodologically weak based on the quality assessment, as they still have the potential to provide new and valuable insights in a field where the literature is relatively sparse.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Uncertainty over content and applicability of data was resolved through discussion within the team.

“If there was any uncertainty over the content and applicability of the data for the review, this was resolved through discussion within the team.”

May combine two claims.

Findings from this mixed methods systematic review suggest that the internet can serve as a useful resource and can potentially improve the patient-HCP relationship if used in the correct way and high-quality sources are accessed.

“yet in contrast findings from this mixed methods systematic review has suggested that the internet can serve as a useful resource and can potentially improve the patient-HCP relationship if used in the correct way and high-quality sources are accessed.”

May combine two claims.

Allowing patients to communicate health information obtained online with their HCP in the consultation, as well as the HCP showing that they value the patients' research, can positively affect the relationship between the two.

“Our findings also demonstrate that allowing patients to communicate health information obtained online with their HCP in the consultation, as well as the HCP showing that they value the patients’ research, can positively affect the relationship between the two.”

May combine two claims.

When HCPs create an atmosphere that is open, this can encourage patients to discuss the information they have discovered; additionally the patient's perception of invading the role of the HCP or their embarrassment may be reduced, which, overall, can enhance the relationship between the patient and HCP.

“When HCP’s create an atmosphere that is open, this can encourage patients to discuss the information they have discovered; additionally the patient’s perception of invading the role of the HCP or their embarrassment may be reduced, which, overall, can enhance the relationship between the patient and HCP [28, 38].”

• cites [28] Ahluwalia S, Murray E, Stevenson F, Kerr C, Burns J. ‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to a consultation. Br J Gen Pract. 2010;60(571):88–94. sourceNot checked yet

  Not checked in the free run.

• cites [38] Townsend A, Leese J, Adam P, McDonald M, Li LC, Kerr S, et al. eHealth, participatory medicine, and ethical care: a focus group study of patients’ and health care providers’ use of health-related internet information. J Med Internet Res. 2015;17(6):e155. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

There is no consistently used terminology to describe the patient-HCP relationship and related aspects.

“Unlike clinical type studies, where each condition or intervention has one universally used term, there is no consistently used terminology to describe the patient-HCP relationship and the aspects related to it.”

Classified as probably not a substantial claim.

The review used a systematic and rigorous approach to identify all relevant literature.

“Strengths of this review includes the systematic and rigorous approach taken to identify all relevant literature.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A review protocol was published to PROSPERO to enhance clarity.

“A review protocol was published to PROSPERO [15] to enhance clarity”

• cites [15] PROSPERO. International prospective register of systematic reviews 2018 [Available from: https://www.crd.york.ac.uk/prospero/.Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The search criterion used was broad in order to cover all areas studied and associated with patient's self-diagnosis and use of the internet.

“Firstly, the search criterion that was used for this systematic review was broad in order to cover all areas that have been studied and that were associated with patient’s self-diagnosis and use of the internet.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Previous evidence found that the internet can potentially have a negative impact on the patient-HCP relationship and can cause barriers in the relationship.

“Although evidence has previously found that the internet can potentially have a negative impact on the patient-HCP relationship and can cause barriers in the relationship [48]”

• cites [48] Caiata-Zufferey M, Schulz PJ. Physicians’ communicative strategies in interacting with internet-informed patients: results from a qualitative study. Health Commun. 2012;27(8):738–49. sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Only English language articles were searched for, which may have reduced the number of potentially relevant studies.

“Only English language articles were searched for, which may have reduced the number of potentially relevant studies.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Sources of information such as conference proceedings, theses and abstracts were not included, which means some related studies may have been missed.

“Secondly, sources of information such as conference proceedings, theses and abstracts were not included, which means some related studies may have been missed.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The review used a robust thematic analysis with conceptualisation through Normalisation Process Theory to aid understanding.

“and a robust thematic analysis with conceptualisation through a theoretical lens Normalisation Process Theory, to aid understanding.”