What is needed for Telehealth to deliver sustainable value to the routine operations of health care in Australia?

Abstract

Telehealth is the delivery of health care services at a distance, using information and communications technology. Telehealth can improve access to health care services through remote consultations, extend care for chronic diseases to the home, make more efficient use of the health workforce, and deliver savings in some aspects of health care. Despite this, telehealth implementation has been slow, fragmented, and frequently short-term. The central research question of this thesis is “What is needed for telehealth to deliver sustainable value to the routine operations of health care in Australia? This question is answered using a mixed methods approach, combining systematic and narrative reviews, economic analysis and a qualitative interview study of key informants. The central research question contains four sub-questions: 1. Can telehealth deliver value to health care? A literature review of reviews synthesised the research evidence, concluding that telehealth can contribute positively to health care, although much research was of low quality and not generalisable. Two further pieces of research make an original contribution to this literature: a) A systematic review of economic analyses of the use of real time video communication in telehealth established that this was cost-effective for home care and on-call specialists, whereas results for rural service delivery were variable. b) A mixed methods evaluation of a service using home video communication to observe patients with tuberculosis was compared to the traditional in-person home visiting observational service. The telehealth service significantly improved the proportion of medication ingestion episodes that were observed, and the economic analysis showed cost-effectiveness. 2. What is the status of telehealth services in Australia? Data were obtained from the published literature, by searching MedLine, CINAHL and Informit databases post-2000, from 37 telehealth services investigated through the qualitative interview study, and from the Australian Government Medicare statistics. Analysis showed that Australian telehealth services are small, fragmented and low volume, comprising a very small percentage of total health care activity. 3. What is needed to increase telehealth implementation? Thematic analysis was conducted on data obtained during interviews with 39 clinicians, managers or researchers associated with 37 telehealth services. Analysis revealed that champions were the key factor in initiating telehealth services; these enthusiastic individuals drove the uptake of telehealth by persuading clinicians of the legitimacy of telehealth, and by building relationships between clinicians. As ethico-legal matters were regarded as a barrier to the uptake of telehealth, these were analysed separately, finding that privacy, security and consent were identified as issues, but that they were manageable in practice. 4. What is needed for telehealth to become routinely sustainable? Further qualitative data analysis using grounded theory methods produced an explanatory model proposing that clinician acceptance was the key factor in achieving sustainability. Clinician acceptance could overcome the major barriers of workforce pressure, low demand, limited resourcing and technology problems. In conclusion, telehealth in Australia remains in an early stage of development. Supporting champions, plus engaging and building relationships between clinicians will enable telehealth to contribute to the overall sustainability of an effective and efficient publicly funded health care system.