Table 4 Barriers, challenges and risks of virtual care
Barriers, challenges, and risks | Example quote(s) |
|---|---|
Patient factors and wellbeing | |
Consumer perceptions: • Choice is important • May not be suitable for severe conditions e.g., heart condition vs. sleep monitoring • Timeliness of urgent care, and what to do in an emergency • Anxiety, if patient uncomfortable with self-monitoring, unfamiliar with clinicians, a mental health patient, living alone, or feeling like they should be in hospital • Fallibility of human follow-up • Lack of education about model, or information about condition and care plan • Inconvenience of carrying heavy and bulky monitoring devices • Model relies on patient disclosure • Impersonal care, concern that the assessment and diagnosis is not thorough enough, or patients feeling like they are being sidelined | “If I was very sick, I wouldn’t want to use this model” Consumer 2 workshop 2 “I feel like this model is better for people with less severe conditions or diseases. For people with more severe situations or diseases, you might miss the best timing to get treated” CALD Consumer 2, workshop 10 “Relies on patient disclosure and ability to pick up problems with their health. It will be difficult for some patients, or some patients won’t be truthful” Consumer 2 workshop 8 |
Provider perceptions: • Limits communication and face-to-face contact • Patient irresponsibility or lack of compliance e.g. patient forgets to use the device or does not follow up on care advice, or patients may try to manipulate data for nefarious purposes such as drug seeking • Characteristics of patients e.g. poor sensory ability, living alone with no carer, or anxious due to self-monitoring • May feel less supported, or lack trust in the system and privacy protections | “Technology gives a false sense of security” Provider 1, workshop 2 “There are some challenges with different cultures who would prefer face to face” Provider 2, workshop 2 |
Accessibility | |
Consumer perceptions: • Feeling disadvantaged if you do not use the model • Subject to availability of doctors and waiting times • Access to equipment e.g. technology may be expensive for health systems and consumers, leading to inequity of access • Education and various competencies needed e.g. time/education to learn how to use the device, English competency, digital literacy, health literacy of the patient or family • Not flexible for all patients | “I would worry about older family members using this model unless they had support (carer or other person)” Consumer 1, workshop 2 “It will be difficult for CALD patient learn how to use the device and interact with the technology” CALD Consumer 1, workshop 10 |
Provider perceptions: • Cost to patient and health system, including maintenance of the model • Accessibility in a timely manner • May not be suitable for paediatric or geriatric patients, or those with low health or digital literacy • Cultural barriers, language and translation, and other considerations for CALD patients • Health inequity if patient cannot access internet and technology | “Interpreters prefer video conferencing. You don’t have the visual information to allow for interpreting over the phone” Provider 10, workshop 6 “Patients that are technologically disadvantaged are too scared and don’t understand how things work, rely on teenagers to do it for them, a lot of people in the older population this is a challenge for them” Provider 1, Workshop 2 |
Resources and infrastructure | |
Consumer perceptions: • Resources needed for full monitoring e.g. need devices, technical support, reliable connectivity, limited value if timeframe of monitoring is too brief • Lack of WiFi infrastructure, with limited coverage, particularly in regional areas and suburbs with blackspots • Need for back-up e.g. availability of emergency services on time to respond in case of device malfunction or gaps in monitoring | “Is there someone at the other end monitoring the results if something happens – will they respond straight away? What if no one is around?” Consumer 2, workshop 2 |
Provider perceptions: • Expensive for health systems to implement e.g. additional staffing requirements such as specialist doctors to read the data 24/7, supply of devices, additional infrastructure such as data storage, maintenance, upgrades • Care and regulation of equipment needed e.g. device malfunction, or machines may be dropped or broken, demand outstripping resources • Need admission pathways for inpatient care other than ED for lower acuity conditions • Technology issues e.g. stable and reliable internet access for patients across the catchment, streamlining and linking of data • Potential workload issues e.g. same amount of work for providers, but may increase workload for senior clinicians, increasing in-flow of ED patients if patients are concerned and do not understand the device alarms, volume of patients that need monitoring • Medico-legal issues around maintaining 24/7 clinician monitoring (which is not considered feasible by providers) | “More admin staff are needed for chronic patients who don’t have someone that can help them. Their children have to take time off work to help them” Provider 2, workshop 2 “Has already been trialled during COVID and found it required more admin staff to help the patients managing the platform” Provider 3, workshop 2 “Looking at Rouse Hill, some areas don’t have the facility for this to be consistently up and running- in remote and older populations their technology might not hold… problems with NBN. This is a big challenge when the NBN goes out” Provider 6, workshop 2 |
Quality and safety of care | |
Consumer perceptions: • Contingency planning must be in place e.g. for technology failures or patient deterioration • Concerned digital monitoring will overtake face-to-face care • Validity and accuracy of monitoring • Relies on consistent patient follow up • Device security and data safety and privacy • Overreliance on technology for assessment of the patient and may miss something | “How do I know this is the best care for my condition? Will it be overused by the healthcare staff because the lack of capacity in the hospital?” Consumer 1, workshop 6 “Ability of doctors to pick up unexpected things will be limited” Consumer 1, workshop 8 |
Provider perceptions: • Device or equipment malfunctioning • Legal ramifications if staff miss something, or if not contacted if an issue arises • Privacy and confidentiality concerns for staff and patients • Need to have safety processes in place in case an event occurs • Adverse events may be more readily picked up in inpatient settings • Qualifications and capacity of person at receiving end of monitoring data • Less control than when in hospital setting • Cannot do physical consults or assessments, less control than when in hospital setting, and less able to see all health cues without physical exam and “seeing” the patient • Not suited to all conditions, or all patients • Unreliability or other limitations of technology e.g. poor WiFi reception in some areas affecting communication, lack of trust in alerts, accuracy of devices and discrimination between genuine event and exertion in sport/exercise • Relies on patient compliance • Places responsibility and greater workload on senior doctors | “What happens if the technology malfunctions?” Provider 5, workshop 2 “if out in the community/outpatient and something happens—who is legally responsible?” Provider 1, workshop 6 “Who is going to take ownership of the information? who will be responsible for it?” Provider 2, workshop 9 “Where do they go if there is an issue? Not many options left for the specialist who was monitoring them or the technicians or physiologists, where do they get the patient reviewed if they notice something, there’s no path rather than being sent to emergency- this needs to be worked on and is a challenge- clinics are full and don’t have the service provision and people who do the monitoring don’t have a clinic” Provider 1, workshop 2 “Could become a “cried wolf” situation – alerts are not trusted to be urgent and assumed to be a false alarm” Provider 7, workshop 6 “There is no way for junior doctors to be involved in this model of care in the current system, thus this model increases workload for senior clinicians.” Provider 4, workshop 2 |