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.

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.

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.

Home videophones improve direct observation in tuberculosis treatment: a mixed methods evaluation.

BACKGROUND: THE USE OF DIRECT OBSERVATION TO MONITOR TUBERCULOSIS TREATMENT IS CONTROVERSIAL: cost, practical difficulties, and lack of patient acceptability limit effectiveness. Telehealth is a promising alternative delivery method for improving implementation. This study aimed to evaluate the clinical and cost-effectiveness of a telehealth service delivering direct observation, compared to an in-person drive-around service. METHODOLOGY/PRINCIPAL FINDINGS: The study was conducted within a community nursing service in South Australia. Telehealth patients received daily video calls at home on a desktop videophone provided by the nursing call center. A retrospective cohort study assessed the effectiveness of the telehealth and traditional forms of observation, defined by the proportion of missed observations recorded in case notes. This data was inputted to a model, estimating the incremental cost-effectiveness ratio (ICER) of telehealth. Semi-structured interviews were conducted with current patients, community nursing and Chest Clinic staff, concerning service acceptability, usability and sustainability. The percentage of missed observations for the telehealth service was 12.1 (n = 58), compared to 31.1 for the in-person service (n = 70). Most of the difference of 18.9% (95% CI: 12.2 - 25.4) was due to fewer pre-arranged absences. The economic analysis calculated the ICER to be AUD$1.32 (95% CI: $0.51 - $2.26) per extra day of successful observation. The video service used less staff time, and became dominant if implemented on a larger scale and/or with decreased technology costs. Qualitative analysis found enabling factors of flexible timing, high patient acceptance, staff efficiency, and Chest Clinic support. Substantial technical problems were manageable, and improved liaison between the nursing service and Chest Clinic was an unexpected side-benefit. CONCLUSIONS/SIGNIFICANCE: Home video observation is a patient-centered, resource efficient way of delivering direct observation for TB, and is cost-effective when compared with a drive-around service. Future research is recommended to determine applicability and effectiveness in other settings.

A qualitative study of ethical, medico-legal and clinical governance matters in Australian telehealth services.

We examined how Australian telehealth service providers perceived and addressed ethical, medico-legal and clinical governance matters arising from service delivery. Thirty-seven telehealth clinicians and managers were interviewed and a qualitative content analysis was conducted. The services covered six Australian jurisdictions and a range of clinical disciplines. There were 11 medical specialities, surgery, mental health, paediatrics, nursing and allied health. Thirty services (83%) used video consulting and 25 (68%) delivered services to rural areas. Telehealth was reported to be beneficial by reducing adverse events, improving health outcomes, offering increased patient choice of service delivery, and improving access to services for rural areas and home care. There were observations of gains or no change in patient-provider rapport compared to face-to-face communication, with some patients reportedly preferring video. Those interviewed reported some problems with privacy and security, and variable informed consent practices. No examples of malpractice were raised, although there was a common misperception that distant providers were not responsible for clinical care. With respect to clinical governance, telehealth was seen as enabling improved quality, integration and implementation of evidence-based care, and to be a major support for the rural health workforce. Although there were potential ethical, medico-legal and governance problems in Australian telehealth services, these had been easily managed in practice.

A systematic review of economic analyses of telehealth services using real time video communication.

BACKGROUND: Telehealth is the delivery of health care at a distance, using information and communication technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase access in health care delivery. This systematic review assesses the economic value of one type of telehealth delivery--synchronous or real time video communication--rather than examining a heterogeneous range of delivery modes as has been the case with previous reviews in this area. METHODS: A systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in June 2009. Studies with patient outcome data and a non-telehealth comparator were included. Cost analyses, non-comparative studies and those where patient satisfaction was the only health outcome were excluded. RESULTS: 36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of care was more important in determining the value of the service than the clinical discipline, the type of technology, or the date of the study. CONCLUSION: Delivery of health services by real time video communication was cost-effective for home care and access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for local delivery of services between hospitals and primary care.