It's important, but not important enough: eHealth as a curriculum priority in medical education in Australia.

Information and communications technology has become central to the way in which health services are provided. Technology-enabled services in healthcare are often described as eHealth, or more recently, digital health. Practitioners may require new knowledge, skills and competencies to make best use of eHealth, and while universities may be a logical place to provide such education and training, a study in 2012 found that the workforce was not being adequately educated to achieve competence to work with eHealth. We revisited eHealth education and training in Australian universities with a focus on medical schools; we aimed to explore the progress of eHealth in the Australian medical curriculum. We conducted a national interview study and interpretative phenomenological analysis with participants from all 19 medical schools in Australia; two themes emerged: (i) consensus on the importance of eHealth to current and future clinical practice; (ii) there are other priorities, and no strong drivers for change. Systemic problems inhibit the inclusion of eHealth in medical education: the curriculum is described as 'crowded' and with competing demands, and because accrediting bodies do not expect eHealth competence in medical graduates, there is no external pressure for its inclusion. Unless and until accrediting bodies recognise and expect competence in eHealth, it is unlikely that it will enter the curriculum; consequently the future workforce will remain unprepared.

How to formulate research questions and design studies for telehealth assessment and evaluation.

Planning a research strategy and formulating the right research questions at various stages of developing a telehealth intervention are essential for producing scientific evidence. The aim of research at each stage should correspond to the maturity of the intervention and will require a variety of study designs. Although there are several published evaluation frameworks for telemedicine or telehealth as a subset of broader eHealth domain, there is currently no simple model to guide research planning. In this paper we propose a five-stage model as a framework for planning a comprehensive telehealth research program for a new intervention or service system. The stages are: (1) Concept development, (2) Service design, (3) Pre-implementation, (4) Implementation, (5) Post-implementation, and at each stage a number of studies are considered. Robust evaluation is important for the widespread acceptance and implementation of telehealth. We hope this framework enables researchers, service administrators and clinicians to conceptualise, undertake and appraise telehealth research from the point of view of being able to assess how applicable and valid the research is for their particular circumstances.

Method-comparison studies in telehealth: Study design and analysis considerations.

When establishing telehealth services, clinicians need to be confident that the examinations, assessments and clinical decisions that they make while using technology are equivalent to conventional best practice. Method-comparison studies are ideally suited to answering these questions, however there is a lack of consistency in the telehealth literature in the study methodologies and data analysis techniques used. Methodologies should closely match clinical practice to maximise external validity and data analysis techniques should match the data types generated in order to be clinically meaningful. In this article we discuss the design, analysis and interpretation of method-comparison studies in the context of telehealth research.

Theoretical frameworks in telemedicine research.

The purposive use of theory is a foundational component of research, which underpins the design, methodology, measures, interventions, and interpretation of the research project. This should be considered from the time the nascent idea of the research is born, until the final interpretation of results and write up of the discussion. Several theories relevant to telemedicine are described, discussed, and linked to typical research questions in the field.

Investigating the preferences of older people for telehealth as a new model of health care service delivery: A discrete choice experiment.

Introduction Telehealth approaches to health care delivery can potentially improve quality of care and clinical outcomes, reduce mortality and hospital utilisation, and complement conventional treatments. However, substantial research into the potential for integrating telehealth within health care in Australia, particularly in the provision of services relevant to older people, including palliative care, aged care and rehabilitation, is lacking. Furthermore, to date, no discrete choice experiment (DCE) studies internationally have sought the views and preferences of older people about the basic features that should make up a telehealth approach to these services. Methods Using a DCE, we investigated the relative importance of six salient features of telehealth (what aspects of care are to be pursued during telehealth sessions, distance to the nearest hospital or clinic, clinicians' attitude to telehealth, patients' experience of using technology, what types of assessments should be conducted face-to-face versus via telehealth sessions and the costs associated with receiving telehealth). Data were obtained from an online panel of older people aged 65 years and above, drawn from the Australian general population. Results The mean age for 330 study participants was 69 years. In general, individuals expressed strong preferences for telehealth services that offered all aspects of care, were relatively inexpensive and targeted specifically at individuals living in remote regions without easy access to a hospital or clinic. Participants also preferred telehealth services to be offered to individuals with some prior experience of using technology, provided by clinicians who were positive about telehealth but wanted all or some pre-telehealth health assessments to take place in a hospital or clinic. Preferences only differed by gender. Additionally, respondents did not feel that telehealth led to loss of privacy and confidentiality. Discussion Our findings indicate a preference amongst respondents for face-to-face pre-telehealth health assessments and, thereafter, a comprehensive telehealth model (in terms of services offered) targeted at those with some technological know-how as a substitute for attendance at hospitals and clinics, especially where these health facilities were far away from older people's homes. The findings may be usefully incorporated into the design of future telehealth models of service delivery for older people.

Mixed methods for telehealth research.

Mixed methods research is important to health services research because the integrated qualitative and quantitative investigation can give a more comprehensive understanding of complex interventions such as telehealth than can a single-method study. Further, mixed methods research is applicable to translational research and program evaluation. Study designs relevant to telehealth research are described and supported by examples. Quality assessment tools, frameworks to assist in the reporting and review of mixed methods research, and related methodologies are also discussed.

Designing quantitative telemedicine research.

When designing quantitative trials and evaluation of telehealth interventions, researchers should think ahead to the intended way that the intervention could be implemented in routine care and consider how trial participants with similar characteristics to the target population can be included. The telehealth intervention and the context in which it is placed should be clearly described, and consideration given to conducting pragmatic trials in order to show the effect of telehealth in complex environments with rapidly changing technology. Types of research designs, comparators and outcome measures are discussed and common statistical issues are introduced.

The Use of Telehealth to Reduce Inequalities in Cardiovascular Outcomes in Australia and New Zealand: A Critical Review.

Telehealth, the delivery of health care services at a distance using information and communications technology, is one means of redressing inequalities in cardiovascular outcomes for disadvantaged groups in Australia. This critical review argues that there is sufficient evidence to move to larger-scale implementation of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services. For cardiovascular chronic disease and risk factor management, telehealth-based services can deliver value but the evidence is less compelling, as the outcomes of these programs are variable and depend upon the context of their implementation.

Improving management of student clinical placements: insights from activity theory.

BACKGROUND: An approach to improve management of student clinical placements, the Building Teams for Quality Learning project, was trialed in three different health services. In a previous paper the authors explored in some detail the factors associated with considerable success of this approach at one of these services. In this paper, the authors extend this work with further analysis to determine if the more limited outcomes observed with participants at the other two services could be explained by application of activity theory and in particular the expansive learning cycle. METHODS: Staff at three health services participated in the Building Teams for Quality Learning project: a dental clinic, a community aged care facility and a rural hospital. At each site a team of seven multi-disciplinary staff completed the project over 9 to 12 months (total 21 participants). Evaluation data were collected through interviews, focus groups and direct observation of staff and students. Following initial thematic analysis, further analysis was conducted to compare the processes and outcomes at each participating health service drawing on activity theory and the expansive learning cycle. RESULTS: Fifty-one interview transcripts, 33 h of workplace observation and 31 sets of workshop field notes (from 36 h of workshops) were generated. All participants were individually supportive of, and committed to, high quality student learning experiences. As was observed with staff at the dental clinic, a number of potentially effective strategies were discussed at the aged care facility and the rural hospital workshops. However, participants in these two health services could not develop a successful implementation plan. The expansive learning cycle element of modeling and testing new solutions was not achieved and participants were unable, collectively to reassess and reinterpret the object of their activities. CONCLUSION: The application of activity theory and the expansive learning cycle assisted a deeper understanding of the differences in outcomes observed across the three groups of participants. This included identifying specific points in the expansive learning cycle at which the three groups diverged. These findings support some practical recommendations for health services that host student clinical placements.

Transitioning a home telehealth project into a sustainable, large-scale service: a qualitative study.

BACKGROUND: This study was a component of the Flinders Telehealth in the Home project, which tested adding home telehealth to existing rehabilitation, palliative care and geriatric outreach services. Due to the known difficulty of transitioning telehealth projects services, a qualitative study was conducted to produce a preferred implementation approach for sustainable and large-scale operations, and a process model that offers practical advice for achieving this goal. METHODS: Initially, semi-structured interviews were conducted with senior clinicians, health service managers and policy makers, and a thematic analysis of the interview transcripts was undertaken to identify the range of options for ongoing operations, plus the factors affecting sustainability. Subsequently, the interviewees and other decision makers attended a deliberative forum in which participants were asked to select a preferred model for future implementation. Finally, all data from the study was synthesised by the researchers to produce a process model. RESULTS: 19 interviews with senior clinicians, managers, and service development staff were conducted, finding strong support for home telehealth but a wide diversity of views on governance, models of clinical care, technical infrastructure operations, and data management. The deliberative forum worked through these options and recommended a collaborative consortium approach for large-scale implementation. The process model proposes that the key factor for large-scale implementation is leadership support, which is enabled by 1) showing solutions to the problems of service demand, budgetary pressure and the relationship between hospital and primary care, 2) demonstrating how home telehealth aligns with health service policies, and 3) achieving clinician acceptance through providing evidence of benefit and developing new models of clinical care. Two key actions to enable change were marketing telehealth to patients, clinicians and policy-makers, and building a community of practice. CONCLUSIONS: The implementation of home telehealth services is still in an early stage. Change agents and a community of practice can contribute by marketing telehealth, demonstrating policy alignment and providing potential solutions for difficult health services problems. This should assist health leaders to move from trials to large-scale services.

Technology support to a telehealth in the home service: Qualitative observations.

INTRODUCTION: The Flinders University Telehealth in the Home (FTH) trial was an action research initiative that introduced and evaluated the impact of telehealth services on palliative care patients living in the community, home-based rehabilitation services for the elderly, and services to the elderly in residential aged care. The aim of this study was to understand the issues encountered during the provision of technology services that supported this trial. METHODS: A mixed methods approach was undertaken to analyse the roles of information and communication technology (ICT) and clinical staff in design, technology management and training. The data sources were staff observations and documents including job logs, meetings, emails and technology descriptions. RESULTS: Use of consumer technology for telehealth required customisation of applications and services. Clinicians played a key role in definition of applications and the embedding of workflow into applications. Usability of applications was key to their subsequent use. Management of design creep and technology services, coupled with support and training for clinicians were important to maintenance of a telehealth service. DISCUSSION: In the setting described, an iterative approach to the development of telehealth services to the home using consumer technologies was needed. The efficient management of consumer devices in multiple settings will become critical as telehealth services grow in scale. Effective collaboration between clinical and technical stakeholders and further workforce education in telehealth can be key enablers for the transition of face-to-face care to a telehealth mode of delivery.

An evaluation of the benefits and challenges of video consulting between general practitioners and residential aged care facilities.

This research evaluated a project that provided video consultations between general practitioners (GPs) and residential aged care facilities (RACFs), with the aim of enabling faster access to medical care and avoidance of unnecessary hospital transfers. GPs were paid for video consultations at a rate equivalent to existing insurance reimbursement for supporting telehealth services. Evaluation data were gathered by direct observation at the project sites, semi-structured interviews and video call data from the technical network. Three pairs of general practices and RACFs were recruited to the project. 40 video consultations eligible for payment occurred over a 6 month period, three of which were judged to have avoided hospital attendance. The process development and change management aspects of the project required substantially more effort than was anticipated. This was due to problems with RACF technical infrastructure, the need for repeated training and awareness raising in RACFs, the challenge of establishing new clinical procedures, the short length of the project and broader difficulties in the relationships between GPs and RACFs. Video consulting between GPs and RACFs was clinically useful and avoided hospital attendance on a small scale, but further focus on process development is needed to embed this as a routine method of service delivery.

The costs and benefits of technology-enabled, home-based cardiac rehabilitation measured in a randomised controlled trial.

We conducted a cost benefit analysis of a home telehealth-based cardiac rehabilitation programme compared to the standard hospital-based programme. A total of 120 participants were enrolled in a trial, with 60 randomised to the telehealth group and 60 randomised to usual care. Participants in the telehealth group received a mobile phone, Wellness Diary and a Wellness web portal, with daily text messaging. Participants in the usual care group received the standard 6-week hospital-based outpatient cardiac rehabilitation programme, including gym sessions. The cost of delivery by telehealth was slightly lower than for patients attending a rehabilitation service in person. From the provider's perspective, the telehealth intervention could be delivered for $1633 per patient, compared to $1845 for the usual care group. From the participant's perspective, patient travel costs for home rehabilitation were substantially less than for hospital attendance ($80 vs $400). Cardiac rehabilitation by telehealth offers obvious advantages and the option should be available to all patients who are eligible for cardiac rehabilitation.

Uptake of telehealth services funded by Medicare in Australia.

OBJECTIVE: The aim of this study is to identify the extent to which the Medicare item numbers and incentives, introduced in July 2011, have been effective in stimulating telehealth activity in Australia. METHODS: A retrospective descriptive study utilising data on the uptake of telehealth item numbers and associated in-person services, from July 2011 to April 2014, were obtained from Medicare Australia. The main outcome measures were number of telehealth services over time, plus uptake proportionate to in-person services, by jurisdiction, by speciality, and by patient gender. RESULTS: Specialist consultations delivered by video communication and rebated by Medicare rose to 6000 per month, which is 0.24% of the total number of specialist consultations. The highest proportional uptake was in geriatrics and psychiatry. In 52% per cent of video consultations the patient was supported by an on-site healthcare provider, most commonly a general practitioner. There were substantial jurisdictional differences. A significantly lower percentage of female patients were rebated for item 99, which is primarily used by surgeons. CONCLUSIONS: Medicare rebates and incentives, which are generous by world standards, have resulted in specialist video consultations being provided to underserved areas, although gaps still remain that need new models of care to be developed. WHAT IS KNOWN ABOUT THE TOPIC?: Video consultations have been rebated by Medicare since July 2011 as a means of increasing access to specialist care in rural areas, aged care facilities and Aboriginal health services. WHAT DOES THIS PAPER ADD?: The uptake of this telehealth initiative has grown over time, but still remains low. For half the video consultations the patient was supported by an on-site healthcare provider, most commonly a general practitioner. Geriatrics and psychiatry are the specialties with the highest proportional uptake. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: New models of care with a greater focus on consultation-liaison with primary care providers need to be developed to realise the potential of this initiative and to fill continuing gaps in services.

Rethinking attitudes to student clinical supervision and patient care: a change management success story.

BACKGROUND: The aim of this project was to explore the process of change in a busy community dental clinic following a team development intervention designed to improve the management of student supervision during clinical placements. METHODS: An action research model was used. Seven members of a community dental clinic team (three dentists, two dental therapists, one dental assistant and the clinic manager), together with the university clinical placement supervisor participated in the team development intervention. The intervention consisted of two profiling activities and associated workshops spread six months apart. These activities focused on individual work preferences and overall team performance with the aim of improving the functioning of the clinic as a learning environment for dental students. Evaluation data consisted of 20 participant interviews, fourteen hours of workplace observation and six sets of field notes. Following initial thematic analysis, project outcomes were re-analysed using activity theory and expansive learning as a theoretical framework. RESULTS: At project commencement students were not well integrated into the day-to-day clinic functioning. Staff expressed a general view that greater attention to student supervision would compromise patient care. Following the intervention greater clinical team cohesion and workflow changes delivered efficiencies in practice, enhanced relationships among team members, and more positive attitudes towards students. The physical layout of the clinic and clinical workloads were changed to achieve greater involvement of all team members in supporting student learning. Unexpectedly, these changes also improved clinic functioning and increased the number of student placements available. CONCLUSIONS: In navigating the sequential stages of the expansive learning cycle, the clinical team ultimately redefined the 'object' of their activity and crossed previously impervious boundaries between healthcare delivery and student supervision with benefits to all parties.

Clinician acceptance is the key factor for sustainable telehealth services.

Telehealth, the delivery of health care services at a distance using information and communications technology, has been slow to be adopted and difficult to sustain. Researchers developing theories concerning the introduction of complex change into health care usually take a multifactorial approach; we intentionally sought a single point of intervention that would have maximum impact on implementation. We conducted a qualitative interview study of 36 Australian telehealth services, sampled for maximum variation, and used grounded theory methods to develop a model from which we chose the most important factor affecting the success of telehealth. We propose that clinician acceptance explains much of the variation in the uptake, expansion, and sustainability of Australian telehealth services, and that clinician acceptance could, in most circumstances, overcome low demand, technology problems, workforce pressure, and lack of resourcing. We conclude that our model offers practical advice to those seeking to implement change with limited resources.

The relationship between telehealth and information technology ranges from that of uneasy bedfellows to creative partnerships.

The relationship between the clinical and technical aspects of a telehealth operation is frequently problematic, and technically-driven projects often fail to achieve sustainability. Qualitative data from a study of 37 Australian telehealth services were analysed to understand how the relationship between telehealth providers and information technology (IT) departments helps or hinders the development of telehealth. The most frequent difficulties reported were between telehealth services and the internal IT departments of health services, rather than with external vendors. The difficulties included barriers to installing telehealth over IT networks, a lack of priority given to telehealth services, and IT departments insisting on standardised approach. Alternatively, when IT staff were assigned to supporting clinical staff and had a close working relationship with them, they were major enablers of telehealth services. Authorising dedicated IT support and encouraging joint problem solving should provide a strong foundation for a healthy relationship which contributes to the growth and sustainability of telehealth.

The role of the champion in telehealth service development: a qualitative analysis.

Telehealth 'champions' are enthusiastic individuals who initiate and promote the uptake of telehealth services. Their role and impact was investigated as part of a qualitative study into the uptake and sustainability of telehealth services in Australia. Semi-structured interviews were conducted with 39 individuals who had been involved in the establishment and operations of 37 diverse telehealth services throughout Australia. A grounded theory analysis was carried out. The results indicated that most services were initiated by champions (25 of the 37). The champions appeared to have three main roles: enthusiastic promotion of telehealth, acting as legitimators, and relationship building. Champions were capable of keeping small scale services operating, but the services were vulnerable to cessation when they lost interest or moved on. As long as participation in telehealth remains optional, the role of the champion will be an important factor in continued operations.