Abstract
This study investigated inpatient acceptance of a unique telemedicine clinical service piloted from December 2022 to June 2023 in 3 rural acute wards in Victoria, Australia. The use of virtual care was complementary to the visiting general practitioner (GP) model common in rural hospitals. The qualitative study employed 3 researcher-designed questions: Did you feel safe using the virtual healthcare doctor?; Did you feel the care you experienced was as it should be? And; If you were offered virtual care again, would you use it? Participants (n = 38) were predominantly over 65 years (95%). Findings describe safe care as being able to understand the virtual doctor, be listened to, and ask questions. Participants affirmed that the care experienced was helpful due to prompt in-hospital clinical interventions organized by the virtual weekend coverage. Most were first-time users of virtual care and recognized that rural doctors need a break. Barriers to acceptance of the service were concerns about the loss of in-person visits with their local doctor and that virtual care could replace local GPs.
Keywords
Introduction
Research acknowledges that rural communities benefit from the availability of telemedicine.1–4 The concept of telemedicine has been used interchangeably with eHealth and telehealth, and broadly applied to all types of telecommunications technology that provide health information, services, and education at a distance.5,6 Recently, and as understood throughout this article, telemedicine refers more specifically to the virtual delivery of clinical services. 7 This research brief reports on an Australian trial of a unique rural inpatient service where clinical care was provided to hospitalized, acute ward patients virtually. This arrangement and patient experiences have not previously been available or reported upon in the Australian rural inpatient context. 1
Clinical Care in the Rural In-Patient Setting
In the Australian rural hospital inpatient setting, general practitioner (GP)—visiting medical officers (VMOs), are largely utilized to manage clinical care in the acute ward. 8 This is due to a lack of fiscal resourcing for rural health services to employ in-situ, salaried hospitalists. To provide hospital-based services local GPs are contracted as VMOs under a fee-for-service model. 8 These arrangements can relieve already over-burdened larger tertiary hospitals, and increase safety, quality, and access to healthcare closer to home for rural populations.8,9 However, the sustainability of the GP-VMO model is problematic as found by a small rural health service in northern Victoria, Australia. Driven by a 75% local reduction in GP on-call availability, tracked from 2017 to 2023, and concerns about local GP workforce burnout, the health service investigated and piloted a telemedicine model of care to provide weekend acute ward clinical coverage.
A Telemedicine Pilot for Rural Inpatients
The pilot was initiated at the health service from December 2022 to June 2023. The introduction of this unique virtual acute ward model encompassed extensive negotiation with an Australian telemedicine provider, whose physicians are credentialed in accordance with the Safer Care Victoria Medical Credentialing and Scope of Clinical Practice Policy. 10 This is a comparable care standard required in all Australian states and territories to provide in-hospital clinical practice. Telemedicine operated exclusively in the after-hours periods from Friday evening to Monday morning to meet all care needs of inpatients virtually. This involved virtual ward rounds using a mobile iPad screen to visit patients at the bedside, actions included: generating referrals; ordering of tests (eg, x-rays, scans, and blood tests), reviewing and organizing medication changes; accepting transfers from tertiary health services; organizing palliative care transfers to ensure rural patients palliated close to home and family; updating of clinical notes and hand-over to local GPs. This research brief reports on rural inpatient's experiences of the telemedicine service during its trial at the local health service.
Methods
This qualitative study aimed to investigate inpatient acceptance of telemedicine in 3 rural acute wards. Inpatient interviews were conducted from February 2023 to June 2023. The study had ethics approval from the University of Melbourne, Ethics Committee, Office of Research Ethics and Integrity. Reference Number: 2023-25567-36201-4. Participation in the study required consent, was voluntary and no incentives were offered.
Study Setting
The study setting involved 3 sites of a rural health service in northern Victoria, Australia. Site one had 6 acute ward beds, site two had 12 beds, and site three had 16 acute beds (total = 34 beds). The healthcare service area was ∼4045 km2 with a population of 30 520 people, 28% of whom were over 65 years of age. 11
Study Participants
Study participants invited to provide feedback about their telemedicine experience were inpatients who had received virtual clinical care at any of the 3 sites of the health service. As part of the inclusion criteria for the research, they had to be over 18 years old and reside in the local government area. They were invited to provide feedback within 48 hours of receiving the service. Study participant exclusion criteria for those not approached to provide feedback included palliative care patients, complex, or deteriorating patients, those with cognitive impairment or in cognitive decline, or those unable to give fully informed consent in English. An information sheet about the telemedicine pilot and a plain language statement about the study were displayed in inpatient wards and hard copies were available to all those invited to participate.
Interview Question Design
The literature was examined to identify current tools specific to, inpatient feedback about telemedicine (clinical services) in the acute ward, which could be adapted for the current study. As a result, 3 questions emerged: (1) Did you feel safe using the virtual healthcare doctor? This question was an opportunity to explore confidence and trust in telemedicine and the virtual physician. 12 (2) Did you feel the care you experienced was as it should be? A question devised for feedback about quality and effectiveness. 13 (3) If you were offered the virtual healthcare option again, would you use it? Versions of this third question are often used to indicate satisfaction or acceptability of the service. 12
Data Collection
Interviews were undertaken face-to-face in the acute ward and required consent. They ranged from 10 to 20 min. To encourage further discussion when receiving a yes/no answer, the prompt of, can you tell me more about that? was used. Researchers recorded interviews with verbatim handwritten notes. These were then transferred to the Research Electronic Data Capture (REDCap) software, a secure data management system. 14 Each participant was allocated a numerical identifier to maintain anonymity, for example, ID.05. The health service site of care was also recorded along with basic participant characteristics such as the inpatient's gender, and age.
Data Analysis
To commence analysis of textual data the 3 interview questions formed categories in a deductive framework. Categories involve direct accounts and use the explicit content of text as descriptions. 15 Verbatim responses were aligned within each category to be presented in a table of results. Duplicate comments were omitted. Inductive content analysis 16 was then completed and reported under 2 themes: enablers to rural inpatient acceptance of telemedicine and, barriers (or moderators) to rural inpatient acceptance of telemedicine.
Findings
In total 38 people who had received the telemedicine service agreed to an interview. Over the pilot timeframe 174 inpatients were provided with virtual clinical care across the 3 health service sites, of these 82 did not meet the study inclusion criteria to be invited to participate in an interview. This equates to 41% of eligible participants being involved in the study. The inability to capture all those eligible for the interview was mainly logistical in the time available to approach inpatients prior to discharge. Individual's privacy to decline the invitation for the interview was respected. Characteristics of study participants who took part in an interview are provided in Table 1. Due to the mainly over 65 years age range participants were grouped according to the commonly accepted age classifications that capture the life stages and needs of older adults; young-old, middle-old, and oldest-old. 17 A summary of findings about safety, care experience, and future use of virtual care and content analysis of enablers and barriers to rural inpatient acceptance of telemedicine is provided in Table 2.
Study Participant (n = 38) Characteristics.
A Summary of Participant Responses About Safety, Care Experience, and Future Use of Virtual Care and Content Analysis of Enablers and Barriers to Rural Inpatient Acceptance of Telemedicine.
Discussion
This study investigated rural inpatient acceptance of a unique telemedicine arrangement that delivered virtual clinical services to hospitalized patients in the acute ward. The hybrid model was structured to be complementary to the existing GP-VMO coverage for inpatients. At the time of the trial, this type of virtual care had not been available to rural inpatients anywhere in Victoria, Australia. Previous research has noted that deeper investigation is required into the factors that affect the acceptance of new approaches, such as telemedicine, in rural health service delivery. 18 The findings show that inpatients, who were mainly from an older demographic, felt safe, care was beneficial, and they were willing to use the virtual service again (see Table 2).
Study participants were mainly over 65 years of age, which is congruent with those hospitalized in Australian rural communities where ∼21.5% are aged over 65 years compared to 15.4% living in metropolitan areas. 19 Past investigations indicate that eHealth, telecare, and telemedicine have increased acceptability within the younger demographic who have medium to higher education. 20 Our study provides important examples of acceptance of telemedicine in the inpatient setting among an older age group. One enabler to acceptance to highlight was the role of the acute ward nurse in facilitating all aspects of the virtual care patient experience (see Table 2). Further investigation is required about the barriers experienced by this group, for example, as indicated in Table 2, innovative options are needed to support inpatients with all their questions during a telemedicine consultation. The problem of GP workforce shortages and the sustainability of VMO arrangements have also been emphasized by this examination of inpatient views. The study participants were concerned about the well-being of their GPs and were aware of the importance of retaining local rural GPs.
Study Limitations
There are critical limitations associated with this study. Patient feedback is vitally important but due to the short timeframe of the pilot we were restricted in the number of interviews undertaken, the diversity of participants (eg, experiences of telemedicine from those below 60 years or non-English speaking), and the amount and type of information collected. The interviews were brief and did not capture detailed information and this limited conducting thematic analysis. However, the interview questions would be useful to test again, possibly in conjunction with specific rural acute ward quantitative surveys about telemedicine.
In addition, further examination about clinical outcomes associated with the use of telemedicine is required, for example, research questions such as “Did weekend access to a virtual GP-VMO shorten the length of inpatient stay or reduce re-admissions?” or “Due to access to telemedicine over the weekend did commencing antibiotics earlier or changing medications or the ordering of further medical tests (eg, x-rays or blood tests) affect treatment regimens and lead to beneficial effects on inpatients?” These are areas for extended research involving telemedicine and its impact on rural inpatients.
Conclusion
Interest in qualitative perspectives about telemedicine is mounting. Our findings have highlighted the barriers to inpatient acceptance with concerns about the loss of in-person visits and the replacement of the local GP workforce. In conjunction with the enablers identified, the study supports telemedicine's potential value when complementary to rural GP-VMO arrangements. A study recommendation is that telemedicine in the acute ward would be a useful addition to relieve the GP workforce in other rural health services struggling with local GP-VMO coverage.
Footnotes
Acknowledgments
The authors acknowledge the Traditional owners of the land on which this study was undertaken, the Yorta Yorta Peoples, and pay our respects to all Elders past and present. The project acknowledges the Australian Government Department of Health and Aged Care Rural Health Multidisciplinary Training programme.
Authors’ Contributions
Dr Carol Reid: Study protocol development, ethics application, data collection, analysis and interpretation of findings, first draft of manuscript, subsequent refinement and editing of paper. Catherine Church: Conceptualization of study, data collection, analysis and interpretation of findings, editing and finalization of paper.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Rural Health Academic Network research position held by the first author builds research and evaluation capacity within rural health services and is supported by the Rural Health Multidisciplinary Training (RHMT) Program. No funding was received for the preparation of this manuscript.
Ethics Approval
The study had ethics approval from the University of Melbourne, Ethics Committee, Office of Research Ethics and Integrity. Reference Number: 2023-25567-36201-4.
Statement of Human and Animal Rights
Not applicable.
Statement of Informed Consent
Not applicable.
