Telehealth in Australia on the Road to Sustained Behavioral Change

Information and communication technologies (ICTs) have been applied in healthcare for decades, albeit with relatively limited application and impact. Times have changed. The Covid-19 pandemic has brought to the fore the need for creative use of technology to deal with challenges and help manage risk. In the presence of the Covid-19 pandemic, use of ICT to mitigate the necessity of face-to-face interaction has become increasingly commonplace. Telehealth has been said to have advanced 10 years in the past 10 months. Applied in a variety of circumstances in a variety of ways, ICT is gaining attention and recognition.
For example, reported Australian National University analysis of Medicare data has illustrated over a 10-fold increase in telehealth services in Q2 of 2020 compared to Q1 recognizing that 71% were still in-person services [1]. Interestingly, 97% of the GP (General Practitioner) telehealth consultations were phone (as opposed to video) services. In a survey of 596 Australian telehealth users, the majority of respondents (n=369, 61.9%) stated that their telehealth experience was “just as good as” or “better than” their traditional inperson medical appointment experience [2]. They went on to conclude that “Telehealth may be worthwhile as a mode of health care delivery while the pandemic continues, and it may continue to be worthwhile after the pandemic.”
Thus, telehealth has had an increased presence, although perhaps not in the form of video conferencing often advocated and has been well received. Whether this is trend for the future and a paradigm shift in healthcare remains to be seen. The question is one of sustainability. To what extent, and in what form, can we expect to see this heightened attention to telehealth persist? The considerations extend beyond technology to aspects and motivations for behavioral change. These include social, process and governance issues. Tradition and professional ethics also come to the fore [3]. Clearly, telehealth sustainability is not exclusively in the domain of ICT. Rather, sustained behavioral change is multi-faceted with synergistic forces and considerations.
Sustainability criteria for telehealth includes demonstrably being used and useful for those intended with customization as appropriate in everyday usage and application. Significant practice-level variation in the USA has been noted accordingly [4]. Telehealth must be economically viable and robust in terms of stakeholder reward. It must also be able to evolve to meet changing needs and scalable within defined contexts. Consideration of ability (or lack thereof) to mandate compliance is important. Ultimately there need to be a portfolio of value propositions. Technology continues to evolve in terms of features and functionality as well as ease of use that is likely to encourage increased telehealth use. The current heavy use of phones is indicative of current application but does not dictate the future. Rather, a portfolio of technology where circumstances can be matched with communication needs and media appropriately chosen is likely with phones relegated to a supporting role. This is in line with both common sense and experience as well as applicable theory [5,6].

Advocates of video conferencing rightly point out to increased degrees of personal interaction attained. Although still limited compared to face-to-face interaction, video is demonstrably better than exclusive use of audio to transmit expressions and remove uncertainties, especially in situations where lack of a common knowledge base exists. This is indeed the case in doctor-patient consultations where medical knowledge needs to be matched with patient conditions. However, technostress has long been recognized in inhibiting extended use of video in patient consultations [7]. Patients accustomed to phone use may not be immediately comfortable (or able) to use video.
Doctors with high levels of medical technical experience may also be reluctant to use video as it immediately exposes their level of discomfort. Further, video may not be deemed necessary (and unnecessarily time-consuming) if the message is straight-forward and the risk of misunderstanding is minimal. Such is often the case with GPs who have a sustained relationship with a particular patient. Indeed, this is currently being reinforced in Australia with a minimum of 1-year patient/GP relationship required to authorize reimbursed billing. Is this situation sustainable? Likely not. A required 1-year patient/GP relationship seems a stopgap that will unnecessarily inhibit patient/GP mobility and establishment of new relationships. Further, increased ease of use and familiarity of video on mobile phones might well see the dominance of phone audio-only use disappear as both doctors and patients become increasingly comfortable and resistant to technostress in this regard. Use of video in consultations may well become the default exonerating video advocates.
Consultations can also easily extend beyond synchronous interaction as circumstances warrant e.g., non-life-threatening/ non-serious and/or general medical advice as well as imagery transmission e.g., skin conditions or minor wounds. Such is the case in asynchronous online health communities (OHCs) becoming increasingly commonplace and demonstrably useful, often as a precursor to synchronous interaction [8,9]. Privacy, however, is but one of many OHC issues [10]. In-home medical monitoring of chronic illness is also on the rise where the doctor may be alerted only when relevant. Technology, however, should not be seen as a panacea to sustained behavioural change. Technology is an intervention and catalyst that is useful but not sufficient. Technology can help achieve sustained behavior change but should not be treated as the equivalent of a “diet pill” that will help to lose weight effortlessly and instantly. Rather, we should view technology as a tool to encourage behavior (e.g., exercising more and eating less) that will lead to long-term success. To be widely adopted and succeed, technology needs to be seen as only one aspect of telehealth implementation.
Social elements are especially important. Friends and family often provide motivation and persuasion in consideration of use of any technology and telehealth is no exception. Adult children can be particularly influential in encouraging expanded telehealth use. Social media can also be useful in helping reduce apprehension on the part of both patients and medical professionals. Teleconsultation among doctors as well as doctor and patient forums are increasingly prevalent as telehealth adjuncts. Processes are an under-appreciated and often-neglected aspect of telehealth that often help assure success as well as practice continuity. Processes promote transfer across time and place and underpin organizational consistency. They can be a source of enlightenment and encourage operational improvement leading to induced efficiency and effectiveness. Processes are also mechanisms for education and training that enable intervention longevity and help assure application success. Finally, governance needs to be in place to help assure against fraud and encourage sustained telehealth use e.g., through Medicare reimbursement. Policies put in place can deal with contingent liabilities as well as open the doors for new forms of doctor/patient telehealth engagement. By so doing, healthcare can more successfully meet the demands of the future as populations age and associated medical expenses proliferate.
In conclusion, the future is challenging but telehealth prospects are bright as integrated technology, social, process and governance elements are brought to bear. Sustained behavioral change becomes more important and evermore evident.

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