Abstract
Background: Emergency department (ED) demand is increasing due to rising patient complexity and an aging population complicated by limited access to general practitioners. Virtual emergency departments (VEDs) have been proposed as an alternative to deliver high-quality care for some ED presentations. This qualitative study explores stakeholder experiences with the Southeast Melbourne Virtual Emergency Department to inform future development of telehealth services. Methods: A qualitative study was conducted utilising semi-structured interviews with 24 stakeholders, including emergency physicians, geriatricians, general practitioners, and residential aged care staff. Content analysis was performed to identify key enablers, challenges, and opportunities for improvement. Results: Stakeholders reported that the VED facilitated high-quality care in the community and worked well by coordinating with follow-up services. Themes identified were that the services were particularly beneficial for older adults and palliative care patients. Challenges included technological limitations and some clinician scepticism about delivering care via telehealth. Further integration with community services and standardised telehealth training were identified as opportunities for enhancement. Conclusions: The VED was perceived as an effective model for community-based emergency care. Future implementations should prioritise clinician training, technological infrastructure, and service integration to optimise patient outcomes.
1. Introduction
In Australia, increasing emergency department (ED) demand has been outpacing population growth [1]. This has occurred partly due to a lack of timely access to general practitioners (GPs) and partly due to an increased prevalence of chronic disease [2,3]. As a consequence, the health system is under pressure, which in turn has flow-on effects. In the ED, this manifests most obviously with overcrowding that may lead at best to poor patient experiences of care, and at worst compromised patient care due to increased demand on clinical resources. Interactions with potentially dissatisfied patients and, in extreme cases, occupational violence and aggression can lead to decreased staff satisfaction [4,5]. Ongoing dissatisfaction from working within a stressed healthcare system may affect workforce retention [6] further exacerbating the issue.
Greater integration of digital technologies into the health system has been proposed to address the increasing demand for emergency care [7]. Telehealth is increasingly being used to assess and manage patients requiring unscheduled care, with services implemented in Victoria and Queensland [8,9,10]. These services were initially developed to assist paramedics by having an emergency physician provide an opinion at the scene of patient pick-up, potentially facilitating the provision of care remotely and avoiding hospital transfer. Subsequently, some telehealth models have expanded to allow requests for consultations directly from patients and provide support to staff at residential aged care facilities and rural health centres [9,11].
Many of these services currently focus on providing only an initial consultation, but maturing telehealth systems may be able to incorporate other elements [12], including remote ambulatory monitoring [13]. This would allow patients to be monitored in their own homes. With enhanced infrastructure allowing real-time transmission of large amounts of biometric data, machine learning could be utilised for early identification of patient deterioration, flagging them for review. While telehealth services are gradually expanding their reach and scope, and some published data on outcomes exists [9,10], there has been limited research into the stakeholder experiences of such services.
The Southeast Melbourne Virtual Emergency Department (SEMVED) was a tele-emergency care service that operated from February 2022 until July 2023. The aim of this study is to describe the experiences and perspectives of the SEMVED service of those involved in delivering or referring patients to the service (ED doctors, residential aged care nurses and managers, in-reach geriatricians and community doctors, and GPs) to inform decisions regarding other large-scale telehealth services currently in operation or development.
2. Materials and Methods
This evaluation consisted of semi-structured online interviews conducted with key stakeholder groups—ED doctors, residential aged care nurses and managers, general practitioners, and hospital in-reach program staff for residential aged care. The study was approved by the Alfred Health Research Ethics Committee (Project ID 280/22) on 25 May 2022.
2.1. Setting
SEMVED was established across three health services (Alfred, Monash, and Peninsula Health) and was run concurrently across their respective catchment zones in collaboration with Ambulance Victoria (AV). EDs in these health services collectively receive approximately 400,000 patients annually, with an average of 342 ambulance arrivals daily. Initially, SEMVED operated from midday to 21:00, seven days a week, accepting referrals from paramedics who, at the scene of patient pick-up, identified patients potentially suitable for remote management. A secure audio-visual platform facilitated real-time interaction and consultation between the virtual emergency department (VED) clinicians, patients, paramedics, and/or aged care facility staff. If deemed safe and suitable by the VED clinician and agreeable to the patient, this model allowed treatment and management at the scene of patient pick-up, thus preventing an in-person ED presentation. The model included ongoing care by sending scripts to the pharmacy and follow-up phone calls to ensure patient stability.
The VEDs could also link patients to other follow-up services, including other hospital-run services (such as residential in-reach) and other community resources (such as urgent care centres/priority primary care clinics and respiratory clinics). The Alfred and Monash VEDs were supported by a care coordinator, who was able to facilitate referrals to outreach services. Another notable point of difference was that The Alfred and Monash VEDs were staffed by clinicians who had no other duties other than to consult in the VED, whereas the Peninsula VED was incorporated into the normal function of the community care team and would balance VED consultations along with the other functions of that department. Other than this, the VEDs operated similarly.
Building on early successes [14], the VED expanded in September 2022 to operate all hours, seven days a week. This expansion included accepting referrals directly from residential aged care facilities and GP clinics and greater collaboration between the services, with Alfred Health covering the entire catchment of SEMVED overnight. Further, “load-sharing” was also introduced during the day, where VEDs could review patients in other catchments to even out workload [6]. In September 2023, government funding for SEMVED ceased, and the state-wide Victorian Virtual Emergency Department (VVED) took over. More details regarding the service have been published elsewhere [8].
2.2. Participant Recruitment
Potential participants were identified by the Alfred GP liaison unit or the Alfred ED management team, who also had contacts at Monash Health and Peninsula Health due to the collaborative nature of the service. Those invited to participate had worked within one of the constituent health services or were potential consumers of the SEMVED. Most of the participants were invited based on their frequent involvement in the service, with the intention of capturing the experiences of clinicians most familiar with its delivery. To complement this perspective, we also invited additional stakeholders to participate in structured interviews to ensure that the analysis incorporated a broader system-level view. This included some who had not utilised or worked within the service as a means of determining what the potential reservations about utilising the service might be. Permission was sought from potential participants before their contact information was passed on to the Monash University researchers. The researchers attempted contact using the details a maximum of three times. Upon agreeing to the interview, participants were provided with the explanatory statement. Participants who completed an interview were given a voucher for AUD 50 to acknowledge their time. Verbal consent was obtained at the start of the recording before the interview commenced.
2.3. Data Collection
Interviews were conducted online using a virtual video-assisted meeting platform and a researcher-developed interview guide (Appendix A) was utilised, with questions that addressed three overarching topics: (1) What worked well? (2) What did not work well? (3) What are the opportunities for the service to evolve?
Interviewers were trained and skilled qualitative researchers (CP, DA, and AB). The interviews were audio-recorded and transcribed using built-in software functions, which were then reviewed for accuracy by the research team. Data were collected over two distinct periods, the first in May to July 2022 (when SEMVED was in service) and the second in October to December 2023 (after the SEMVED operation had ceased).
2.4. Data Processing and Analysis
A conventional content analysis methodology set out by Hseih and Shannon [15] was employed in this study to enable direct information and perspectives to be obtained from participants without applying existing ideas or theories. A stepwise approach was undertaken; researchers familiarised themselves with the data during the transcript-checking process, and the transcribed interviews were imported into NVivo. Coding was conducted using a combination of deductive and inductive approaches: initial codes were informed by the research questions and interview guide (deductive), while additional codes emerged from the data during analysis (inductive). Three coders (CP, DA, and AB) independently reviewed and coded the transcripts. Discrepancies in coding were discussed in meetings and resolved through consensus to ensure consistency and reliability. This process led to the development of conceptual themes through content analysis.
3. Results
In total, 24 stakeholders participated in the service (see Table 1) over two distinct data collection periods. In 2022, thirteen participants were interviewed; in 2023, eleven were interviewed. Staff were interviewed from the EDs of the hospital organisations, participating residential aged care facilities, general practice, and residential in-reach services. Of the 24 participants, 17 had used or worked in the VED service.
Table 1.
Participant characteristics.
3.1. What Worked Well?
3.1.1. High-Quality Patient Care in the Community with Efficient Follow-Up Services
Participants perceived the patient care provided by the VED to be of a high quality that facilitated efficient follow-up in the community (Table 2). This included a description of good patient outcomes, patient satisfaction with the service, and shorter wait times. Eleven participants expressed satisfaction with the provision of high-quality care, noting that the VED provided care to patients in their own homes that was comparable to what they would have received in a physical emergency department. One ED clinician highlighted that a key strength of the service was the ability to focus on one patient at a time and offer longer consultations. This contrasted with the physical ED, where there might be multiple competing demands, and doctor–patient interactions are not likely to be as long in duration.
Table 2.
Participant comments on what worked well.
It was also perceived that the service enabled greater utility of the skills and abilities of other pre-existing services. For example, two participants discussed that paramedics could use their skills in assessing patients and administering treatments. The VEDs could link patients to other follow-up services, including other hospital-run services (such as residential in-reach) and other community resources (such as urgent care centres/priority primary care clinics and respiratory clinics). The care coordinator role used within Alfred and Monash Health was described as a helpful resource by the VED clinicians due to their advanced knowledge of the available community pathway referrals.
3.1.2. Appropriate Avoidance of In-Person ED Presentation
All participants agreed that unnecessary in-person ED presentations were avoided through the appropriate diversion of patients suited to receive care in place. This saved many patients from being sent to the ED, which, in the case of older adults, may have been “incredibly traumatic” and, in some cases, resulted in physical harm (e.g., risk of falls). Additionally, the service was considered effective at identifying patients who did require hospital transfer and facilitating the ability to pre-prepare for their arrival, with the VED clinician being able to advise the ED team of the transfer, request investigations, and suggest an initial plan for assessment and management.
3.1.3. Benefits for an Older Patient Cohort
Interviewees recognised that the VED was beneficial for a range of patient cohorts, including those with complex needs and those with COVID-19. In particular, emergency physicians, geriatricians, and residential aged care facility (RACF) staff felt that it was valuable to avoid transfers of RACF residents, specifically those with dementia. One RACF staff member relayed that without the service, residents would return from the ED distressed following a disorientating visit. Another specific scenario where the VED was perceived to be of benefit was for patients requiring palliation, with one VED clinician acknowledging that the service enabled this to be provided in a comfortable and familiar environment rather than in the ED or on a hospital ward.
3.1.4. Access to Patient Notes and Local Knowledge
In addition to highlighting the importance of a senior clinician (GP or emergency physician)-driven model with strong collaboration between services, a major facilitator of the VED model was the duality of access to patient notes and a high degree of knowledge of available local health resources and services. Access to patient records, which provided comprehensive accounts of recent care, was considered extremely valuable in making decisions during virtual consultations. Supplementing this, local knowledge of the referral pathways and community support available was also noted as beneficial. These advantages were raised in the context of the pending shift to a single state-wide service, and there was concern that this considerable benefit would be lost.
3.2. What Did Not Work Well?
3.2.1. Technology Systems Varied in Usability and Adoption
During the interviews, seven clinicians discussed technology as a significant barrier to the provision of the VED (Table 3). This included the quality of internet coverage and phone reception, which was particularly bothersome to Monash Health and Peninsula Health participants. However, Alfred Health participants did not report this issue to the same extent, highlighting potential equity issues.
Table 3.
Participant comments on what did not work well.
3.2.2. Workforce Rostering and Service Provision Processes Hindered Delivery
Barriers concerning workforce rostering and service provision processes were discussed. An Alfred Health ED consultant highlighted issues with staff rostering, noting that overnight, the VED consultant was responsible for working in the physical ED while also attending to their virtual commitments. During the day, clinicians would be dedicated solely to the VED, which was deemed more effective due to the lack of competing demands.
Despite comments about the benefit of the VED regarding its linkages to follow-up services, the in-reach clinicians felt that the limited capacity of these follow-up services restricted the VED service’s functionality. It was noted that fewer staff within those follow-up services were being rostered on weekends and that no staff were available to review patients overnight.
3.2.3. Individual Working Preferences and Stakeholder Perceptions Varied
From three participants in the first data collection period (who had not yet worked in the VED), there was concern that telehealth was not the same as practising medicine in the ED, and they would prefer not to be part of the telehealth service. There was also criticism that the service did not address the most significant issues contributing to ED overcrowding. They explained that this was considered a limitation of inpatient beds and that diverting a few patients from attending the ED was not likely to have a significant impact. Others noted that some of the referrals to the VED might have otherwise not been transported to the ED typically. Thus, it was perceived that the VED was not necessarily meeting an unmet need.
3.3. What Are the Opportunities for the Service to Evolve?
3.3.1. Greater Integration with Community Services
Following the loss of funding to the SEMVED, four participants highlighted that there might have been a missed opportunity to improve the integration of the VED into local community services (Table 4). The three health services operated with some differences, and Peninsula Health staff pointed out that their community care team model enabled an efficient and connected system by managing in-person follow-ups themselves, as the community care team oversaw both the VED and the community follow-up programs. This was seen as beneficial in optimising the function of the VED.
Table 4.
Opportunities for the service to evolve.
3.3.2. Greater Definition of Roles and Duties for VED Clinicians
Whilst the VED was establishing its function, there were a relatively small number of calls. This resulted in time between calls where it was felt other work could be carried out. Both Peninsula Health and Monash Health staff suggested that other non-urgent tasks performed by emergency physicians as part of their non-clinical duties could be completed during this time, such as reviewing pathology results. For instance, Alfred VED clinicians took calls that would otherwise go to the in-charge consultant in the physical ED, which prevented the emergency physician from being interrupted from urgent tasks.
3.3.3. Formalised Training for VED Providers
Whilst one consultant did not see the need for training, most felt more training would be beneficial. Participants discussed the need for a formalised training and credentialling process as the VED moves forward.
Themes from stakeholders are summarised below (Table 5).
Table 5.
Summary of themes.
4. Discussion
Our work examines the diverse experiences of individuals working with a VED service (SEMVED). It is the first study looking into the perspectives of staff working with or within an Australian VED and in so doing addresses the “staff experience” dimension of the quadruple aim that is currently lacking in the existing literature. Although SEMVED is no longer operational, large-scale state-wide services operating under similar frameworks have been established in Western Australia, South Australia, Victoria, and Queensland, attracting hundreds of millions in funding. This study provides insights that are directly relevant to policymakers, service designers, and clinicians in Australia and internationally.
Clinicians found that this model facilitated the provision of quality care, which benefited patients. The service could be improved further through standardised training for the delivery of emergency telehealth and increased collaboration with community programs. Emergency telehealth services should also be mindful that appropriate technological and clinical support is required to ensure success. In particular, care should be taken to ensure a reliable broadband connection and suitable pathways for arranging patient follow-ups. The ability to access local medical records and the opportunity to develop relationships with local facilities and community in-reach services were additional benefits of the VED service.
Prior research supports the potential of telehealth to enhance community-based care. MacNeil et al. conducted a qualitative study in the UK examining the experiences of primary care staff with telehealth for patients with chronic conditions [16]. Consistent with our findings, their study reported that telehealth was well-received as a supplementary approach to care delivery and was perceived to benefit patients. Similarly, Shah et al. found that delivering care via telehealth was particularly beneficial for older adults [17]. They explored the use of telemedicine within senior living communities, finding it an effective way to reduce unnecessary ED visits and provide accessible patient care within the comfort of a familiar environment.
The barriers to delivering care via telehealth are similar to those identified previously. Technological barriers, including connectivity issues, have previously been cited as an issue [18], and it has been suggested that 24 h technological support is a necessity for services delivering telehealth [19]. Our finding that clinicians found the work satisfying was partly due to the opportunity to focus on one patient at a time and deliver quality care. Concerns raised by clinicians in this study about having to simultaneously care for patients in the physical emergency department and via telehealth are echoed in a study by De Guzman et al., which found that general practitioners often felt the quality of care they provided through telehealth was hindered by time pressures [20].
In our study, some stakeholders, particularly those who had not worked within the service, were sceptical about its benefits. Previous research highlights that a key element in the success of a telehealth program is confirming that medical practitioners are both willing and prepared to use telehealth and digital care solutions [18]. It has been suggested that allaying these concerns may involve demonstration of patient benefits [21], and it seems likely that ongoing robust evaluation of patient outcomes and experiences will be beneficial in this regard.
The existing qualitative literature evaluating services utilising models similar to SEMVED is limited. Thus, there are no published prior insights on how a service such as ours might be improved. However, the need to focus on training clinicians on the delivery of telehealth is considered by many to be an important priority as telehealth gradually expands its footprint in the health system.
4.1. Future Directions
There is potential for mature telehealth services to offer additional benefits, such as removing the barrier of distance and thereby allowing the exportation of medical expertise to any hospital or clinic, as well as providing remote follow-up utilising technologies such as remote ambulatory monitoring. Further ongoing robust evaluation is required as the scope of telemedicine expands to ensure that services are delivered optimally, efficiently, and safely while still providing patient benefits and acceptable care experiences.
4.2. Limitations
This study was conducted over two distinct periods, and, as such, some of the findings may have been more applicable to one time period over another. In addition, due to the range of participant roles, some of the findings were borne from the experience of one or two participants from a single role. Those who agreed to be interviewed may have been more enthusiastic about the service, leading to some selection bias. Further, a more complete evaluation would have included insights from additional stakeholders involved in care delivery, including Ambulance Victoria staff and the care coordinators who supported virtual clinicians. Gaining the patients’ perspectives would also provide valuable insights for improving the design of virtual health services.
5. Conclusions
Healthcare providers perceived that the SEMVED was able to deliver high-quality care. The service could be improved further through standardised training for the delivery of emergency telehealth and increased collaboration with community programs while also ensuring that any service is supported by the appropriate technological infrastructure.
Author Contributions
Conceptualisation, M.S.-G.; data curation, A.B. and C.P.; formal analysis, A.B., C.P. and D.A.; investigation, D.A.; methodology, A.B., C.P. and D.A.; writing —original draft, M.S.-G.; writing—review and editing, M.S.-G., A.U., C.C., F.M., B.M., G.O., P.C. and D.A. All authors have read and agreed to the published version of the manuscript.
Funding
This work was supported by funding from the Southeast Metro Health Service Partnership.
Institutional Review Board Statement
Ethical approval for this project was obtained from the Alfred Health Human Research Ethics Committee (Project ID: 280/22) on 25 May 2022, with site-specific authorisation granted from Monash and Peninsula Health.
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The data presented in this study are available on requested from the corresponding author to protect the privacy of participants in the study.
Conflicts of Interest
The authors declare no conflicts of interest.
Correction Statement
This article has been republished with a minor correction to improve its formatting. This change does not affect the scientific content of the article.
Appendix A. Interview Guide
| Questions for RACF or GP Participants |
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| Questions for Alfred Health, Monash Health, Peninsula Health, Residential In-Reach Staff Participants |
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