Where to next for telehealth in Australia’s health services?

THERE is currently much discussion about the future of telehealth in Australia. We have heard a number of perspectives highlighting the benefits and challenges of further expanding the use of telehealth (here, here, here, here and here) however, the perspective of the acute hospital sector has been less vocal.

Here we outline how the recent changes in the use of telehealth in response to the coronavirus disease 2019 (COVID-19) pandemic have affected health services and patients, and we provide some thoughts on the key factors for a successful integration and expansion of telehealth through acute health services after COVID-19.

Western Health serves one of the fastest growing and diverse populations in Australia. Growth in the Western Health catchment is significantly above the national average, consistently outstripping forecasts. The rate of population growth is rising and expected to grow from a current population of 800 000 to well over 1.2 million people by 2026. More than 30% of our community were born outside of Australia, at least 110 different languages are spoken, with around 8% of the population having poor or no English proficiency; significantly higher than the national average of 2.6%. These factors combine to have a significant impact on the health and wellbeing of the population, so Western Health provides major services in chronic and complex disease, cancer and mental illness, including one of Victoria’s biggest drug and alcohol services. In addition, the birth rate is forecast to increase from around 5500 births per annum to over 7200 births per annum by 2026.

This increase in demand, coupled with the large proportion of children in the catchment, means there will be a continuing and increased need for appropriate health services across the lifespan from birth until death. However, the expansion of health and social service capacity in the West has not matched the rapid population growth in this area. In the current resource-constrained climate, it is essential that health care providers optimise current resources through alternative models of care, achievable through a more embedded telehealth program.

Our previous experience with telehealth has been that while desired by many consumers, the overall implementation of telehealth has been slow and fragmented (here, here, here and here). Substantial efforts have gone into scaling up the routine use of telehealth, often with limited success. In Australia, despite the introduction of generous financial incentives for specialist videoconsultations, telehealth represented less than 1% of all specialist consultations provided.

The introduction of the COVID-19 telehealth program at Western Health has led to major changes in health care delivery, with an impact on organisational (staff) and technological levels. There has been substantial organisational uptake and engagement with virtual modes of service delivery, an alternative avenue of patient contact during periods of isolation, and less travel due to the COVID-19 pandemic. There has also been a suggestion of a reduction in the “did not attend” rate for clinic appointments; however, there is not yet any formal assessment of the impact on and experience of patients.

The informal experiences of our staff and patients at Western Health with the new telehealth Medicare item numbers has reinforced our belief that telehealth should become a mainstream component of our health system. Staff have generally been positive about its implementation, while noting some concerns that need to be addressed. Staff particularly noted that the platform was easy to use and patients, and staff have fed back to us that they prefer videoconferencing to phone consults because they can see each other.

However, it is clear that implementation of telehealth as mainstream across our health services needs to be informed by more formal evaluations of patient and health worker capabilities, the impact on patient experience, safety and outcomes, including equity and diversity of access and experience, health worker experience, and implications for health system costs and sustainability. We have already learnt that attention will need to be paid to a number of areas for a successful transition across our health services. These include:

1. Patient involvement. It is important to consider the social, organisational, and technological factors affecting both patients’ and clinicians’ adoption of mobile health tools and telehealth conferences. Patient involvement will be required to identify usable and meaningful solutions. It is also crucial to avoid feelings of loneliness, stress and anxiety, which may worsen physical symptoms, in particular, when serving an area with a population from low socio-economic groups, with low health literacy, high prevalence of mental health disorders, and chronic and complex conditions. Patient involvement will be critical to address the risk to health equity stemming from the digital divide.
2. Upskilling and training. With the very rapid transition to telehealth, skill gaps have been identified, ranging from required capabilities for optimal use of the available technologies through complex role changes, to deliver tasks in a different environment, to changes in education delivery, to online and simulation teaching. Western Health is one of the only health services in Victoria which is a registered training organisation (RTO). As an RTO, Western Health would also be able to offer an accredited qualification for telehealth after completing minimum training and experiential requirements.
3. Funding models. Telehealth has demonstrated the capacity to better integrate primary care with the health service. While this is to the benefit of consumers and health professionals, it challenges our current funding models. More flexible funding systems between health services and primary care will be essential. Funding will also be required to meet the challenges, including ongoing expenses, to require and maintain technology, training of staff and outreach to people who are unable to adapt or transition to telehealth consultations. Ongoing funding to ensure capabilities training, logistics and optimal platforms and interoperability will also be required.

Addressing these challenges for ongoing delivery of telehealth through Australia’s health services has the potential to deliver many benefits to patients, through transforming patient experience and moving health care delivery to more targeted consultations, with less inconvenience, cost and time. Reaching population groups that may otherwise be hard to reach, hence delivering more equitable access to health care, is another benefit. Health services and systems benefit through decreasing the costs of consultations and increasing the opportunity to provide integrated big data to develop more efficient models of care.

Bodil Rasmussen is Chair in Nursing and Director for the Centre for Nursing Research in the Western Health Partnership and Institute for Health Transformation, Deakin University. She is an international leader in diabetes research and education, holds Adjunct Professorial appointments the Universities of Copenhagen and Southern Denmark and leads numerous e-Health teams to improve health services for people with chronic and multi-morbidity conditions.  

Dr Paul Eleftheriou is the Chief Medical Officer at Western Health. He received national recognition for his contribution to the practice of medical administration and for his initiatives around improving medical accreditation processes. He holds a Masters in Health Administration through La Trobe University and is committed to innovation, quality improvement and achieving improved patient outcomes.

Lily Liu joined Western Health in 2018 and successfully implemented the first phase of WH’s 7-10 year EMR journey.  Preparation is now underway for the second phase which will be the largest digital health project implemented by WH. Miss Liu also led the Telehealth implementation project at WH during the COVID crisis in Victoria.

Linda Sweet is Chair in Midwifery at the Western Health Partnership and the Institute for Health Transformation, Deakin University. She is an international leader in midwifery education, holds Adjunct Professorial appointments Flinders University and the University of Newcastle, and leads numerous maternity care teams to improve health services for pregnant women and their families.

Dr Richard Horton is the Chief Medical Informatics Officer and the Director of the Department of Anaesthesia, Pain and Perioperative Medicine at Western Health. He has interests in education, health informatics and medical leadership and management. He is a specialist anaesthetist and obtained a Graduate Certificate in Health Professional Education from Monash University in 2006. In 2011 he completed the Clinicians at the Helm Management and Leadership Program. He has played a number of leadership roles within the Australian and New Zealand College of Anaesthetists and Western Health. He is committed to improving the ability of clinicians to provide the best care to their patients and recently this has been through the better use of technology.

Professor Anna Peeters is Director of the Institute for Health Transformation, and Professor of Epidemiology and Equity in Public Health at Deakin University. She is Past President of the Australian and New Zealand Obesity Society, and in 2014 was awarded the World Obesity Federation Andre Mayer Award and a Churchill Award.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA, or InSight+ unless so stated.