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General practice / Family practice
Original research
Telehealth use in Australian primary healthcare during COVID-19: a cross-sectional descriptive survey
  1. Elizabeth J Halcomb1,
  2. Christine Ashley1,
  3. Sarah Dennis2,
  4. Susan McInnes1,
  5. Mark Morgan3,
  6. Nicholas Zwar3,
  7. Anna Williams4,5
  1. 1School of Nursing, University of Wollongong Faculty of Science, Medicine and Health, Wollongong, New South Wales, Australia
  2. 2Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
  3. 3Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
  4. 4School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
  5. 5School of Nursing and Midwifery, University of Notre Dame Australia, Sydney, New South Wales, Australia
  1. Correspondence to Anna Williams; anna.williams{at}westernsydney.edu.au

Abstract

Objective This study aimed to investigate Australian primary healthcare professionals’ experiences of the rapid upscaling of telehealth during COVID-19.

Design A cross-sectional survey.

Participants and setting Two hundred and seventeen general practitioners, nurses and allied health professionals employed in primary healthcare settings across Australia were recruited via social media and professional organisations.

Methods An online survey was disseminated between December 2020 and March 2021. The survey comprised items about individual demographics, experiences of delivering telehealth consultations, perceived quality of telehealth consultations and future perceptions of telehealth.

Results Telephone was the most widely used method of providing telehealth, with less than 50% of participants using a combination of telephone and video. Key barriers to telehealth use related to the inability to undertake physical examination or physical intervention. Telehealth was perceived to improve access to healthcare for some vulnerable groups and those living in rural settings, but reduced access for people from non-English-speaking backgrounds. Quality of telehealth care was considered mostly or somewhat the same as care provided face-to-face, with actual or perceived negative outcomes related to missed or delayed diagnosis. Overwhelmingly, participants wanted telehealth to continue with guaranteed ongoing funding. Some 43.7% of participants identified the need to further improve telehealth models of care.

Conclusion The rapid shift to telehealth has facilitated ongoing care during the COVID-19 pandemic. However, further work is required to better understand how telehealth can be best harnessed to add value to service delivery in usual care.

  • COVID-19
  • Telemedicine
  • Organisation of health services
  • Quality in health care
  • PRIMARY CARE

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-065478

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • An online survey was used to reach primary healthcare professionals across Australia to explore their experiences of telehealth.

    • Although the sample size is modest, the inclusion of doctors, nurses and allied health professionals provides a unique multidisciplinary insight into telehealth use.

    • There was diversity of participants in terms of professional group, geographical location and experience levels.

    Introduction

    After more than two years since the first cases of COVID-19 were identified in Wuhan, China, the long-term impact of the pandemic on future health system design in Australia and internationally is becoming clear. Governments are exploring ways to provide healthcare more efficiently and safely, drawing on experiences from the pandemic. In Australia, primary healthcare (PHC) provides the front line for delivery of healthcare and is universally accessible. Previously in Australia, the delivery of health services via telehealth was limited apart from the provision of specialist medical services to rural and remote communities.1 However, its use was expanded during the pandemic as a means to minimise the spread of COVID-19 by reducing face-to-face consultations, and to offer continuity of health service delivery.2 Government funding for telehealth consultations via Medical Benefits Schedule (MBS)-funded telehealth items was initially restricted to medical practitioners but later expanded to include some PHC nurses, community-based midwives, nurse practitioners and allied health professionals.

    Telehealth is defined as ‘the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance’.3 Research undertaken on telehealth prior to COVID-19 demonstrated that, compared with face-to-face healthcare, telehealth can provide lower cost care with similar service use and outcomes.4 5 Telehealth has also been demonstrated to be acceptable to patients and health professionals and is associated with high levels of satisfaction.4 5 Despite its benefits, telehealth can present a barrier for those who are challenged in accessing or using technology.1

    A key challenge to implementing telehealth within health systems has been the complexity of the change to service delivery. Regulation, professional accountability, funding structures and individual preferences and skills have slowed the implementation of digital systems.6 7 The capacity for telehealth to impact widely on future PHC service delivery will be dependent on the PHC workforce being confident and competent to use these new technologies and integrate them within usual care models to optimise patient outcomes. Given its novelty and rapid roll-out, there remains limited evidence relating to the use of telehealth across diverse Australian PHC professions.8 This paper reports on findings from a national multidisciplinary PHC survey which explored experiences of using telehealth during the rapid upscaling of this service that occurred during the COVID-19 pandemic.

    Methods

    This paper reports on a cross-sectional survey undertaken as part of a mixed methods study exploring PHC professionals’ experiences of the introduction of telehealth in Australia. Data from the subsequent qualitative interviews are reported elsewhere.

    Participants and recruitment

    Australian PHC professionals were surveyed online between December 2020 and March 2021 via Qualtrics.9 People were eligible to participate if they were doctors, nurses or allied health professionals employed in a PHC setting. As there is no central register of PHC professionals in Australia it was not possible to identify or contact these individuals directly and so the survey was distributed via a multifaceted strategy. This included dissemination of the survey link via social media (LinkedIn, Facebook, Twitter) and email/newsletters produced by key professional organisations, including the Australian PHC Nurses Association, Allied Health Professions Australia and Australian College of Nursing. Snowballing was also used to distribute the survey via relevant professional networks.

    Determining sample size in descriptive studies is challenging, particularly when the size of the population is not known. In this study, we sought to recruit 10 participants for each key item in the instrument.10 Given there were 20 key items, we sought to recruit 200 participants. During the study period, 217 eligible participants completed the survey.

    Instrument

    A survey tool was developed based on existing literature and previous research undertaken related to COVID-19 by the researchers1 11 12 (online supplemental file 1). The survey was divided into four sections. The first section collected demographic information about the participants and their employment. The second section investigated participants’ experiences of establishing telehealth in their practice. The third section explored the experience of delivering telehealth consultations, the quality of telehealth consultations and the perceptions of telehealth. The impact of telehealth on consultations was measured by eight items rated on a 5-point Likert scale from ‘strongly disagree’ to ‘strongly agree’. The quality of telehealth was measured by nine items modified from Bhandari et al.13 Each item was rated on a 4-point Likert scale from ‘strongly disagree’ to ‘strongly agree’. The final section explored the future of telehealth. This section sought key messages that participants would like to send policy makers/governments about telehealth and its future in clinical practice. Prior to dissemination, the survey tool was reviewed by five multidisciplinary clinician researchers to ensure face validity and ease of completion. This resulted in a few minor modifications to wording or survey logic before the survey was distributed.

    Patient and public involvement

    Insights into issues related to the impact of COVID-19 on PHC professionals were gleaned from previous research by the authors and personal insights from professional engagement. There was no other patient or public involvement.

    Data analysis

    Survey data were exported from Qualtrics9 into SPSS V.25.0.14 The data were summarised using descriptive analyses, including means, SDs and frequency distributions. Given the relatively small number of allied health professionals from each discipline these were collapsed into a category of ‘allied health’ for analysis. Statistical significance was set at p<0.05.

    Results

    Participants

    Two hundred and seventeen participants who met the inclusion criteria responded to the survey. Most participants were female (n=182; 83.9%) and employed in a group general practice (n=96; 44.2%) (table 1). Participants’ mean age was 48.2 years (SD 12.3) and they had been practising for a mean of 20.4 years (SD 13.4). Some 65.0% (n=141) of participants were employed in metropolitan areas.

    View this table:
    Table 1

    Participant demographics

    Half of the participants (n=110; 50.7%) had not completed any specific training/education about telehealth technology or equipment use. Similarly, 47.0% (n=102) of participants had not completed any specific training/education about how to deliver a telehealth consultation prior to the COVID-19 pandemic. However, since the start of the COVID-19 pandemic, 34.6% (n=75) of participants had engaged in training/education about how to deliver a telehealth consultation and 29.9% (n=65) of participants had engaged in training/education about telehealth technology or equipment use.

    Use of telehealth

    Eighteen (8.3%) participants described regularly using telehealth in their practice prior to the COVID-19 pandemic, while 53.9% (n=117) had never used telehealth prior to COVID-19. Since the outbreak of COVID-19, 92.2% (n=200) of participants had undertaken telehealth consultations. Of these, 40.6% (n=88) described undertaking telehealth consultations via phone only, while 49.3% (n=107) identified that they had undertaken telehealth consultation via both telephone and videoconference. The only participants who reported using videoconferencing alone were five (2.3%) allied health professionals. The most used software to deliver telehealth was Zoom (n=55; 25.3%), followed by Skype (n=28; 12.9%), FaceTime (n=22; 10.0%) and Microsoft Teams (n=19; 8.8%).

    Telehealth consultations

    Despite the widespread uptake of telehealth, face-to-face remained the predominant mode of consultation. Indeed, 43.3% (n=94) of participants reported that more than three-quarters of their consultations were still being conducted face-to-face. Only 22.6% (n=49) of participants reported undertaking fewer than half of their consultations face-to-face. Just under half of participants (n=102; 47.0%) used phone consultations for up to a quarter of their consultations. While most general practitioners (GP) (n=61; 93.8%) and three-quarters of the nurse participants (n=52; 78.8%) conducted over half of their consultations face-to-face, only 67.3% (n=33) of allied health undertook more than half of their consultations in person.

    Figure 1
    Figure 1

    Impact on access.

    There was a statistically significant association between the use of video and professional group. Significantly fewer allied health professionals than doctors (p=0.0005) or nurses (p=0.004) undertook less than half of their consultations via video. There were also significant associations between telephone use and professional group. Significantly more doctors compared with nurses (p=0.01) and significantly more nurses than allied health professionals (p=0.02) undertook less than half of their consultations via phone. This demonstrates the differences in modes of telehealth between professional groups.

    There was diversity in decision-making as to whether a consultation was conducted via telehealth or face-to-face, with most participants describing a combination of approaches to decision-making. While 45.6% of participants (n=99) indicated that patients were asked their preference when booking a consultation and 31.3% (n=68) described patients indicating a preference during online booking, other described reception staff (n=88; 40.6%) or health professionals (n=78; 35.9%) triaging consultation mode at booking. Only 11.5% (n=25) of participants indicated that the online booking system helped patients to decide the best consultation mode.

    While approximately half of participants described face-to-face consultations as most appropriate for different consultation types (table 2), phone consultations were felt to be more appropriate for COVID-19 concerns and prescription requests.

    View this table:
    Table 2

    Type of consultation most used in various presentations

    Barriers to telehealth

    The factors participants indicated constrained the delivery of telehealth most were the availability of physical examination/tests (mean 3.06), opportunity to deliver a physical intervention (mean 2.96) and the availability of visual cues (mean 2.61) (table 3). Factors reported to have the least impact on telehealth were the participants’ telehealth (mean 1.78) and information technology (IT) skills (mean 1.70). Factors such as IT support or connection quality were reported to have minimal impact for most participants.

    View this table:
    Table 3

    Barriers to telehealth use

    Access to care

    A higher proportion of participants perceived that people from non-English-speaking backgrounds experienced reduced access to care because of telehealth compared with other vulnerable groups (figure 1). A higher proportion of participants perceived that older people living at home, people living with a disability, low-income earners and those living in rural areas had improved access to care following the introduction of telehealth.

    Quality of care

    While 39.2% (n=85) of participants felt that the quality of care delivered via telehealth was about the same as face-to-face care, 27.2% (n=59) described it as somewhat and 3.2% (n=7) described it as much worse. In contrast, only 6.9% (n=15) of participants described care delivered via telehealth as somewhat as or much better than face-to-face care. There was no significant difference in the perceptions of care quality between doctors, nurses and allied health professionals (p>0.05).

    Compared with face-to-face consultations for a similar presenting issue, 56.3% (n=98) of participants described telehealth consultations as being a little (n=72; 41.4%) or a lot (n=26; 14.9%) shorter. However, 8.6% (n=15) of participants described telehealth consultations for a similar issue as being longer than face-to-face consultations. There was no significant difference in perceived length of consultation between professional groups (p=0.152).

    Fifteen participants (6.9%) identified that they had undertaken telehealth consultations that had resulted in a negative or potentially negative outcome. A further 28 (12.9%) participants indicated that they may have undertaken telehealth consultations that resulted in a negative or potentially negative outcome. Most of these negative outcomes (n=25; 60%) were related to missed or delayed diagnosis. There was no significant relationship between negative outcomes and practice location, practice type, professional group, age or previous use of telehealth (p>0.05).

    Future of telehealth

    Participants overwhelmingly stated that they would like to continue to use telehealth beyond COVID-19. While 46.7% (n=78) of participants wanted to continue to use telehealth as deployed during the pandemic, 43.7% (n=73) of participants considered that improvements to future models of telehealth could be made through four key areas, including: improved funding for service provision, enhanced platforms and software for telehealth delivery, greater use of videoconferencing and increased patient education for engagement in telehealth consultations. Most participants (n=110; 65.9%) would reconsider their use of telehealth if the MBS items (government funding) for telehealth were ceased. Of these, 46.1% (n=77) reported that they would stop delivering telehealth consultations and 19.8% (n=33) would only provide a limited telehealth service if funding were discontinued.

    Discussion

    Summary

    This paper has explored the experiences of Australian PHC doctors, nurses and allied health professionals in upscaling telehealth use during the COVID-19 pandemic. Participants identified that telehealth was largely conducted via telephone and was most suited to consultations which did not require physical assessment. Telehealth was perceived to provide improved access to healthcare for some patient groups and quality of care was predominately reported as being better or comparable to face-to-face consultations.

    Strengths and limitations

    Exploring telehealth across PHC professions was a key strength of this study as it sought to capture a multidisciplinary perspective. However, given the modest sample size, the number of participants in each professional group made it difficult to explore the differences between groups. Despite a gender-neutral focus in recruitment, most participants were female. This is, in part, due to the number of nurses recruited and the female dominance of the nursing profession. The modest sample size likely reflects the heavy workloads and workforce challenges during the pandemic that left limited time for research engagement. While the use of an online survey may have facilitated participation across a wide geographical area, it may also have impacted response as it required participants to access the online platform. Additionally, those who responded may have a more polarised view about telehealth than those who did not participate. Finally, this survey only presents the experiences of PHC professionals. Further research to explore the perceptions of various patient groups is important to provide a multidimensional picture of the impact of this model of care.

    Comparison with existing literature

    The COVID-19 pandemic has resulted in the increased use of telehealth internationally, as a means of providing safe clinical services to support traditional face-to-face health provision.15 16 As identified in our study, the successful uptake of telehealth is reported in various studies according to factors such as familiarity with and availability of video equipment,11 patient and health professional preference16 17 and the nature of consultations.18 Most studies exploring the use of telehealth focus on its use by medical practitioners,6 19 nurses8 11 and patient experiences.20 This study builds on existing reports, focusing on its use in PHC in diverse clinical consultations by multidisciplinary health professionals.3 21

    Our findings that telephone consultations were the preferred method for delivering telehealth were in keeping with other international literature.22 It is also perhaps not surprising with telephone technology being readily available in all PHC settings and patient homes, and familiar to both health professionals and patients. However, various studies have explored experiences of using video in preference to telephone or face-to-face consultations.4 23–25 A systematic review undertaken prior to the COVID-19 pandemic by Rush et al.26 found that from the perspective of patient outcomes, video consultations were comparable with telephone consultations and had the additional benefit of being able to undertake visual assessment when required. Our study identified that a lack of visual cues and ability to undertake physical assessment was a major barrier to telehealth use. This finding suggests that wider use of video as the mode of telehealth consultation may assist in expanding the scope of problems managed via telehealth in the future. While video consultation may require additional equipment, software and IT skills both for the provider and the patient, its advantages were overlooked by many of our study participants. The widespread use of videoconferencing platforms by individuals and families during the pandemic suggests that this should be more widely considered by health professionals in future telehealth service planning.

    Participants in this study mostly perceived consistency between the quality of healthcare delivered via telehealth and face-to-face care. This is consistent with the findings of a study of Australian health consumers,27 which found consumers’ telehealth experience just as good or better than traditional consultations. Despite reports of high patient satisfaction, there has been limited exploration of the impact of telehealth on care quality and there are few tools to measure the impact of telehealth on quality of care. In some studies, the issue of not being able to identify subtle visual cues during a telehealth consultation has been identified as a potential threat to care quality and risk to patients.8 28 Such observations highlight the importance of health professionals being educated and skilled in delivering quality consultations virtually. However, the issues around mode of healthcare delivery and care quality are an area that should be further investigated as telehealth is increasingly used to deliver healthcare.

    Participants in this study perceived that many patient groups would have improved access to healthcare because of telehealth. These included people living in rural areas, low-income earners, those with a disability and older people. Seeing telehealth as an enabler of access to care has been reported in other PHC studies.1 11 The value of being able to have consultations without needing to travel and wait in a clinic, being able to access prescriptions through virtual consultations and not having to physically risk attending the clinic are reported advantages of telehealth.1 However, as noted in the findings of this study and the literature,1 29 not everyone experiences improved access to care. This highlights a need, as we develop telehealth models, to ensure that the specific needs of individuals and groups, particularly those who are vulnerable, are considered to ensure that care access remains equitable.

    Telehealth became the flagship of Australia’s COVID-19 response. The importance of ongoing funding via the MBS to support this model of care was considered critical by participants in this study. Previous reasons for the government’s risk averse approach to funding telehealth services in general practice have been cited to be related to provider overservicing, fraud and individual overutilisation.30 The importance of reviewing funding models to sustain, modify and expand the future use of telehealth across health settings has become an important focus internationally as reviews of health system responses to COVID-19 are undertaken.31–33 The Australian government appears to have listened to the calls for permanent MBS item numbers for telehealth, with an announcement in April 2022 that MBS telehealth introduced on a temporary basis in response to the COVID-19 pandemic will become permanent. These include services provided by GPs, medical practitioners, nurse practitioners, midwives, allied health providers and dental practitioners.34 As we move into a new era of blended healthcare delivery it is important that the integration of telehealth within the PHC model of care is critically evaluated to ensure that it enhances access, quality of care and outcomes for both providers and patients.

    Implications for practice

    Telehealth uptake in Australia and internationally has rapidly grown because of the disruptive influence of COVID-19. This study has demonstrated that telehealth has the potential to improve access and deliver care of comparable quality as face-to-face consultations by PHC professionals. While participants in this study have embraced the use of telehealth, several issues need to be addressed to effectively embed telehealth in the new normal of postpandemic PHC. First, further research is needed to understand the reasons for the predominance of telephone consultations over videoconferencing and to determine which modality achieves the best outcomes. Additionally, while telehealth improved access to care for some, it marginalised others. Support is needed to ensure that the community can adapt to and access telehealth delivered care. This study highlighted that missed or delayed diagnoses can be an issue in telehealth. Further investigation of such outcomes is required to determine causation and identify strategies to mitigate this risk. Finally, the continuation of telehealth in Australia is contingent on ongoing funding to support this mode of healthcare delivery by all health professionals across the multidisciplinary PHC workforce.

    Conclusion

    The COVID-19 pandemic has provided an opportunity to shift PHC delivery to incorporate telehealth within usual care. While that has a range of advantages, some caution remains around ensuring that PHC professionals are supported to develop skills in telehealth consultations and that there is access to quality IT equipment to promote quality of care. Additionally, ongoing funding of telehealth models is vital to ensure the sustainability of this mode of care delivery. As we transition into the new era of healthcare it is vital that there are ongoing critical evaluations around the use of telehealth to ensure that it enhances accessibility, promotes efficiency and ensures quality of PHC service delivery to optimise patient health outcomes.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The study was approved by the Human Research Ethics Committee of the University of Wollongong (approval number: HE2020/161) and ratified by the University of Notre Dame Australia (approval number: 2020-056S). Participants were guaranteed confidentiality as survey responses were not identifiable. Consent was implied by survey completion.

    Acknowledgments

    We would like to thank the PHC professionals who generously participated in this study. Thanks also goes to the Australian College of Nursing for supporting this work.

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    Footnotes

    • Twitter @LizHalcomb, @sue_mcinnes

    • Contributors EJH, CA, AW, SD, SM, MM and NZ made substantial contributions to conception and design of the study and interpretation of data. EJH performed the analysis and is the guarantor. EJH, CA, AW, SD, SM, MM and NZ contributed to drafting of the paper and revised the paper’s clarity and content before approving for publication.

    • Funding This work was funded by the University of Notre Dame Australia as part of a larger investigation around COVID-19 in primary healthcare funded by the University of Wollongong and Australian College of Nursing.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.