Considerations for establishment of a private virtual hospital identified using an implementation science approach

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Considerations for establishment of a private virtual hospital identified using an implementation science approach

This study identified a comprehensive list of barriers, enablers and considerations for design and implementation of a virtual hospital, and demonstrated the importance of using evidence-based implementation theories, frameworks and processes in the pre-implementation phase. Seven major implementation determinants and 53 considerations were identified (Table 2). The broad range of identified determinants will enable the health service to make crucial adaptations to improve the likelihood of suitability, acceptability and uptake of the virtual hospital. The need for a long-term vision and clear principles for the virtual hospital was a strong message. This research addressed critical implementation research gaps12,13.

The major barriers identified, for the most part, aligned with previous research, with some notable differences. Australian private hospital funding mechanisms are currently restrictive, representing a critical barrier to establishment of private virtual hospitals. This is a novel finding not represented in previous literature. At the time of writing, the Australian Government’s Health Insurance Act39 Health Insurance Determination 2021 allows Medicare Benefits Services payments for a specialist doctor to conduct a face-to-face consultation with an admitted patient, or a telehealth consultation with an outpatient, but not a telehealth consultation with an admitted patient. This funding restriction has substantially impacted the viability of private virtual hospitals in Australia. This finding is broadly in alignment with previous research in the Australian public hospital system27. In both sectors, funding models were found to stifle virtual healthcare innovation. There was also alignment with previous studies on the need for a clear vision and purpose for the virtual hospital27, strong governance structures and clinical processes27,28, safety concerns about virtual healthcare21, the importance of trust and relationships with key stakeholders7,27,40, workforce challenges and training needs27, and technological limitations and challenges7,27. These are consistent findings across varied settings, including public and private hospitals and different countries, indicating that these determinants are important to consider in virtual hospital planning, acknowledging that there may be differences between contexts.

Differences between clinicians’ perceptions of virtual healthcare suitability and acceptability were found between studies. In our study, clinicians’ perceptions of virtual healthcare suitability differed for various conditions. These perceptions appeared to be influenced in part by exposure to virtual healthcare models: for the most part, greater exposure related to higher perceived suitability. Schultz et al. reported clinicians in their study had a high level of acceptance of virtual COVID-19 care overall7. By contrast, Shuldiner et al. found that clinicians’ perceptions of the suitability of virtual healthcare varied18, and this was a major influence on whether they had normalised virtual healthcare. These discrepancies highlight the need for further exposure of clinicians to virtual healthcare models, additional training in virtual consultation practices, and further research to understand in more detail how clinicians’ attitudes towards virtual healthcare vary across disciplines, settings and levels of exposure. Based on Shuldiner et al.’s findings it will be important to ensure that clinicians working in a virtual hospital perceive the value of their work and feel that they are able to operate at their full scope of practice. Although there were differences on some other points between participants, e.g., the drivers and tension for change at an individual level, there were no substantial differences in responses between disciplines or types of stakeholders. Where there were minor differences of opinion, these have been noted in Table 2.

Consumers and carers expressed a strong preference for face-to-face healthcare over telehealth, although they acknowledged that these perceptions had changed to some extent during the COVID-19 pandemic. This reflects a large body of research on the perceived acceptability of telehealth (e.g.,41,42). Strategies such as care navigation can be effective in improving the perceived acceptability of telehealth modalities43, and it may be necessary to consider incorporation of a care navigation or concierge service within the new virtual hospital. Another novel finding raised by participants was the opportunity to maintain or re-engage a clinical workforce who may not wish to or cannot continue traditional face-to-face clinical care, e.g., due to an injury. The flexibility with hours and locations that virtual hospital care offers was seen as attractive to clinicians.

From an organisational readiness to change perspective, although there was substantial goodwill and motivation for change, there was a lack of confidence due to technical and funding barriers, and a lack of understanding of the overarching vision of the virtual hospital. Participants from all groups expressed concerns about the risks of virtual consultation and the potential for misdiagnosis or inappropriate treatment prescription. Interestingly, participants reported differences in their risk calculation for people living in metropolitan versus rural and remote areas. In Queensland, Australia there are vast geographical distances between rural and remote population centres and a consumer may be multiple days driving distance from their closest tertiary hospital, therefore timely access to medical care is lacking. Where a patient lived near a physical hospital, the expressed preference was for face-to-face healthcare, with virtual healthcare considered substandard. However, for patients unable to access a physical hospital in a timely manner, a virtual assessment was considered by participants to be appropriate, and an improvement on the current lack of timely healthcare options. This indicates a tacit acceptance of a lower standard of care based on circumstance. This is a novel finding, and we have expanded on this in a separate manuscript44. This discrepancy between the expected care standard in metropolitan versus rural areas highlights known healthcare inequities experienced by people in rural areas45.

Providing healthcare ‘in place’ through virtual mechanisms aligns with the global push for ageing ‘in place:’ providing necessary care and supports in the community to enable older people to remain in their home environment, connected to social and community networks.46 Consumers reported their high budgetary priority of private health insurance because it enabled them to access specialist doctors in a timely manner. This willingness to pay more to access specialists aligns with Vo et al.’s review of discrete choice experiments eliciting patients’, healthcare providers’ and policymakers’ preferences and willingness to pay for virtual care.47

With its emphasis on remote consultation specifically, the PERCS Framework provided an appropriate set of domains for planning of a virtual hospital23. Telehealth consultation brings with it specific risks, challenges, and advantages that differ from the implementation of other types of clinical services. Having admitted inpatients being clinically treated in their home or community increases the complexity of virtual hospitals. PERCS compared favourably for this study with the Nonadoption, Abandonment, Scale up, Spread and Sustainability (NASSS) Framework33, which is commonly used to guide the implementation of technological innovations, and the Consolidated Framework for Implementation Research48, a determinants framework commonly used when conducting a context assessment. PERCS provided a more suitable guide for this study due to the explicit inclusion of constructs focusing on the home environment and the clinical consultation. It is common practice in implementation science research to adapt and combine theoretical approaches and frameworks to suit the context of individual projects. In this case, the framework required adaptation to suit the Australian private hospital context by adding VMOs as a stakeholder group, and having a greater focus on funding models. Additional research is necessary to understand the safety and effectiveness of virtual hospital models. It will be important to evaluate new virtual hospital models using a hybrid implementation-effectiveness design to determine clinical, service and implementation outcomes for patients, carers, staff, VMOs and the healthcare service. The perspective of informal carers, including the burden that caring for an inpatient in their home may represent for informal carers, is a critical gap in existing literature. This is an important area for future research, as informal carers are likely to be a key healthcare workforce for many virtual hospital models of care.

Implications for policymakers, clinicians, healthcare decision makers and health insurance providers

The major barriers identified in this study related to government and health insurance funding models. The authors encourage Australian policymakers to consider amending legislation that currently restricts the payment of Medicare Benefits Scheme item numbers for medical consultation by telehealth for admitted patients. Likewise, the authors encourage policymakers in other countries to consider how existing funding models may stifle virtual hospital innovation. For healthcare decision makers planning to implement a virtual hospital, Table 2 provides a useful guide to barriers and enablers for consideration. Pre-implementation virtual hospital research needs to be complemented with tailored implementation strategies to address the identified barriers and enablers, and evaluation of implementation outcomes. This should be a focus for future research. Technological interconnectivity, accessibility, reliability and internet access are critical for a virtual hospital but not currently a reality, particularly for people living outside of major Australian cities. This was witnessed during interviews where video conferencing software experienced multiple lags and outages that influenced the flow of conversation and created delays. Australian governments need to invest in higher speed and more reliable internet services across Australia to enable efficient, reliable and safe virtual hospitals.

Strengths and limitations

This study addresses an important gap in knowledge by outlining a comprehensive set of critical barriers and enablers to the establishment of a virtual hospital. The study used a novel, evidence-based, multi-theoretical implementation science approach which enabled a broad range of barriers and enablers to be identified. There was strong interest from participants, with the majority of invitees agreeing to an interview. Although this study was specific to the Australian private hospital context, the list of considerations is relevant internationally in both public and private settings, noting that the specific determinants may differ based on context. There is a risk in all qualitative studies that the interpretation of data may be influenced by the perspectives and biases of the researchers. We have used reflexivity strategies to minimise the impact of any biases, such as having multiple coders, and an inclusive multi-stakeholder research team who all contributed to the interpretation of data. The decision to focus on role representation rather than saturation also limits the generalisability of these results. Additional participant groups not included in the scope of this study may need to be consulted. These include general practitioners and other stakeholders who are likely to refer patients to the virtual hospital, a more diverse consumer group, including consumers and carers from rural and remote areas, First Nations peoples, and clinical staff who will be directly providing remote consultations. We collected limited demographic data from participants and acknowledge that additional demographic information such as age and ethnicity may better contextualise these results. All consumers were current patients or clients of the health service which means their responses may be influenced by their relationship with the health service. Therefore, caution must be used in the interpretation of these data, as they will not be representative of a broader health service user population.

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