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Private virtual hospitals offer an unprecedented opportunity to improve timely access to hospital care, especially for people in rural and remote areas, but critical barriers need to be addressed.
In the past five years, we have seen a rapidly growing evidence base for the effectiveness of virtual health care. This has led to an international push to move beyond narrowly focused telehealth services or COVID-19 wards and towards establishment of full-scale virtual hospitals providing remote inpatient care.
Virtual hospitals offer more than just telehealth. Inpatient models generally utilise hybrid designs including medical and nursing care via telehealth, along with remote monitoring devices (eg, COVID-19 wards) and/or face-to-face visiting nursing services (eg, hospital-in-the-home [HITH]).
Virtual hospitals are not a replacement for traditional hospitals, but they will play a critical role in supporting those patients who require hospital-level inpatient care and can be safely and effectively managed in their home environment.
Well designed virtual hospitals can have equivalent or better clinical and mortality outcomes to traditional hospitals, reduce the need for travel for people in rural and remote areas, and result in high patient satisfaction. More research is needed on informal/family carer burden, which is likely to be one of the downsides of virtual hospitals.
There is little evidence, however, to guide health care providers on virtual hospital establishment. Many existing virtual hospitals were implemented in an impromptu manner in the context of the COVID-19 pandemic, requiring adaptation and learning on the go.
A recent Cochrane Library editorial highlighted the lack of research on the design, implementation, sustainability, and scaling of HITH services. This is consistent with the lack of implementation research on other virtual hospital models.
Although virtual hospitals are in operation in Australia, these are predominantly in the public sector, with some private psychiatric hospitals offering HITH services. Of the 12.1 million hospital admissions in Australia in 2022–23, 41% were in private hospitals, so the lack of private virtual hospitals is a missed opportunity for private patients.
What do private hospital providers need to consider?
The bulk of the virtual hospital research internationally has been in the public sector and cannot simply be generalised to the private sector due to substantial differences in funding, staffing and business models. We aimed to provide a guide to private hospital providers on barriers, enablers and areas for consideration prior to establishing a virtual hospital.
Our team at Wesley Research Institute used an implementation science approach to identify 53 considerations for establishing a private virtual hospital in Australia. Our research identified critical issues impacting the viability of private virtual hospitals.
First and foremost were restrictive funding models that stifle opportunities for innovation. For instance, the Australian Health Insurance Act (Health Insurance Determination 2021) includes Medicare item numbers for a medical specialist to provide a face-to-face consultation with an inpatient, or a telehealth consultation with an outpatient, but explicitly excludes telehealth consultations with an inpatient — a core component of most virtual hospital models.
Other barriers included:
- Technological challenges and the need for upfront investment: this includes secure electronic medical records that can be updated reliably and remotely by clinicians in the home, and are adaptable over time as new services and technologies are incorporated.
- Communication challenges, especially between health providers in different sectors. For instance, if an inpatient in a private virtual hospital experienced a medical emergency and was taken to a public emergency department, this raises clinical governance, legal and funding issues.
- Workforce issues: although virtual hospitals were seen to create an opportunity to re-engage a skilled workforce, eg, nurses who had left clinical work due to injury, finding and training the right workforce may still be challenging.
- Some health insurers had been reluctant to date to support virtual hospital models of care.
Many clinicians we interviewed expressed reticence about the suitability and safety of virtual health care, and a reluctance to refer patients to a virtual hospital if they had access to a traditional hospital. However, these same clinicians were often enthusiastic about the potential for virtual hospitals to improve access to hospital care for patients in rural and remote areas.
Some clinicians were willing to accept a lower standard of care for those outside of major cities because they considered it better than the lack of services currently available in many rural areas. Hospital providers will need to be aware of this potential bias to ensure that virtual hospitals, particularly those intended for people in rural and remote Australia, are designed and delivered to the same high quality and safety standards as would be expected in a traditional hospital.
What needs to change to improve private virtual hospital viability?
Health care providers can address many, but not all, of the 53 barriers and enablers identified in this research without support from policy makers.
Only the Australian Government can amend the Health Insurance Act (Health Insurance Determination 2021, Section 3C, Clause 7(1)) to allocate medical specialist telehealth item numbers for patients admitted to a virtual hospital, thus removing a major barrier to private virtual hospital viability.
Change will not happen overnight. Virtual hospital providers will need to collaborate with external providers to ensure that patients can access the care they need as they traverse between private and public traditional and virtual hospitals and general practice. Improved and streamlined communication processes are necessary, and this will likely require the input of state and federal governments.
Virtual hospitals have the potential to be transformative in the Australian health care landscape, improving geographical equity and timely access to hospital-level care. We urge policy makers to work with the research community and health leaders to clear the way for virtual hospital innovation.
Dr Olivia Fisher is a Senior Research Fellow and Virtual Hospitals and Healthcare Research Program Lead at Wesley Research Institute and Senior Lecturer at Charles Darwin University.
Dr Caroline Grogan is a Research Fellow at Wesley Research Institute and Adjunct Research Fellow at the University of Queensland.
Kelly McGrath is a PhD Student at Charles Darwin University, based at Wesley Research Institute, and Mental Health Care Navigator for Isaac Navicare.
The authors do not work for, consult, own shares in, or receive funding from any company or organisation that has a conflict of interest relating to this article. Olivia Fisher receives funding from UnitingCare Queensland. Caroline Grogan receives funding from UnitingCare Queensland and the Irene Patricia Hunt Memorial Trust. Kelly McGrath receives funding from the Australian Government Department of Industry, Science and Resources via an Elevate Scholarship, Wesley Research Institute, UnitingCare Queensland, Mitsubishi Development, and the Catalano Family Foundation. This research was funded by UnitingCare Queensland, and was conducted by Wesley Research Institute.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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