Table 3.

Qualitative results: normalisation process theory

	Coherence	Cognitive participation	Collective action	Reflexive monitoring	Risk of bias^a
Dikomitis et al (2015)³²	The eCDST raised awareness of potential cancer symptoms and alerted GPs to possible risks Outputs such as positive predictive values were valued less than other components of the eCDST	Participants questioned the robustness of the research and expressed a desire to understand the research behind risk calculations Acceptability and useability would have been enhanced had the training been more comprehensive	Incompatibility with other clinical systems, not fitting in with usual workflow Uptake of the eCDST was dependent on time pressures in consultations Perceived extra pressure on secondary care Prompt overload On-screen prompts took attention away from the patient	Not addressed	Low risk
Chiang et al (2015)³³	GPs could make sense of the eCDST and identify its benefits eCDST alerted GPs to the potential presence of cancer Provided a tool to reassure patients at low risk Interpretation of how eCDST should be used differed between GPs	Low prevalence of cancer diagnoses in primary care meant that GPs would rarely consider using the eCDST ‘Cancer suspicion was unnaturally heightened’ GP characteristics such as age and experience impacted uptake of the eCDST A disagreement between the eCDST suggestion and the GPs’ clinical assessment led to mistrust of the risk model	Variation in GP use, interpretation of the history and symptoms entered Potential to raise anxiety and lose control of the consultation. ‘Prompt fatigue’ GPs felt the eCDST should be integrated into general practice clinical software eCDST was not considered compatible with current work practices	No monitoring or resources to adapt or evaluate the intervention	Low risk
Jiwa et al (2006)³⁵	Not addressed	Lack of confidence in the eCDST	The eCDST created additional tasks to the referral process Variation in GPs’ views about what constitutes an urgent referral	Not addressed	High risk
Kidney et al (2017)³⁴	GPs were more likely to refer if the recommendation fit with current guidelines	Personal judgement was used to override patients who were flagged It was clear GPs would refer if they were suspicious of cancer, but not all symptoms flagged up were viewed as suspicious by GPs	Consideration of the effect on patient anxiety resulted in not referring those flagged by the algorithm Resource pressure and being told to reduce unnecessary referrals (competing demands)	Not addressed	Low risk
Summary	In three of the four studies, GPs described the eCDSTs as valuable, suggesting the role of these tools in assisting with diagnosis has a place in primary care. They reported that the eCDSTs raised their awareness of symptoms indicative of cancer. In contrast, GPs had different interpretations of how and when the eCDSTs should be used, with some using it with patients who were asymptomatic	Clinician buy-in was identified as one of the limiting factors to successful implementation; disconnection and mistrust of the eCDST occurred when the recommendations conflicted with the GP’s intuition or clinical judgement. Buy-in was stronger if recommendations were in line with clinical knowledge and aligned with the GP’s judgement	Compatibility of the eCDST in current practice and — at an organisational level — was a common barrier across all four studies. The barriers occurred at the interpersonal, clinical, and health-system levels. Introducing the tool disrupted the consultation, with GPs reporting feeling a loss of control. At the clinical level, additional tasks and time pressures impacted clinical flow. At a health-system level, the prompts for referral placed extra pressure on secondary care	There was limited evidence about how GPs monitored and adapted the new interventions over time. No study reported any system in place to monitor and adapt the eCDST to ensure sustainability over time. This important construct is not being considered at the point of implementation

↵a Risk of bias score calculated according to Joanna Briggs Institute Critical Appraisal Checklists.¹⁶ eCDST = clinical decision support tool.