Virtual Care Operational Framework

Virtual care is the delivery of healthcare and related services where care is provided by using information and communications technologies rather than through face-to-face consultation. Virtual care can be used by healthcare providers for medical, nursing, allied health, patient education, pharmacy services and support workers. It is an overarching term encompassing telehealth (telephone and video-enabled), telemedicine, tele-education, teletherapy, telemonitoring and remote monitoring. Virtual care is a modality used to connect and provide care – it connects clinicians or any other person(s) responsible for providing care to patient(s) and carer(s).

The use of virtual care has been associated with supporting and providing tertiary consultations in ambulatory settings. Consumers and health care providers across Victoria have benefited from the increased flexibility and service choice made possible through virtual care.

Implementing virtual care requires a commitment to innovate, challenge current practice and explore all delivery possibilities using available technology as the tool. It is expected that, as a system, there will be a need to overcome barriers and enhance system enablers as services adapt to new ways of practice. To date, the adoption of virtual care has delivered many benefits to consumers, healthcare providers and organisations. Notably, these benefits include the capacity for virtual care to be cost-effective, improve clinical outcomes via consumers to access care near to real-time and a convenient alternative to the more traditional face-to-face healthcare, professional advice, and education.

Virtual care is part of a connected patient journey that may move between face-to-face care and virtual care in a manner that is clinically safe, and acceptable to both patient and provider. Clinical governance models apply equally regardless of environment and should not be any different to services provided within a bricks and mortar facility or through virtual medium.

These benefits will continue to grow as virtual care is further incorporated as part of routine healthcare service delivery in the future.

Benefits of Virtual Care

Virtual care offers many benefits to consumers, their families and carers, clinicians, healthcare providers, and the broader health system. Care delivered via virtual care modalities add value to an existing service, allow a service to be provided where it previously was not available or allow provision of services in a more efficient or effective manner.

Virtual care can assist in addressing some key barriers to equitable access of health care by providing an easily accessed and low-cost mode of service delivery. However, it is important to note that the benefits are not necessarily experienced equally or equitably by all patients.

The benefits include ^1,2,3:

• Patient-centered care: greater flexibility of choice for consumers about how and where they receive care and reduced inconvenience and stress through care received closer to home
• Reduced travel and associated costs for the consumer
• A safe and low-risk way for clinicians, service providers and consumers (including immunocompromised patients) to continue important health services when requiring physical distancing
• Reduction in fail-to-attend would provide safety benefits for consumers and clinicians beyond the current pandemic – e.g., winter, flu outbreaks
• Faster and more equitable access to services, especially for care that might not otherwise be available locally.
• Care can be provided in socially or culturally safe and supported environments
• Improved integration and quality of care, e.g., opportunities for multidisciplinary care and inclusion of carers across primary, community and acute care, particularly for people with chronic conditions
• Less reliance on retrieval services to transfer and transport patients who would have otherwise been required to attend a face-to-face appointment
• Greater scope for support and reduced professional isolation and capacity building for rural and remote clinicians
• Where secure information sharing arrangement in place between health services, a ‘load balancing’ capability across the sector, where demand is uneven, clinicians in one health services can support other services under pressure

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¹Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC public health. 2020 Dec;20(1):1-9.

² Fisher K, Davey AR, Magin P. Telehealth for Australian general practice: The present and the future. Aust J Gen Pract. 2022 Aug:626-9.

³ Snoswell CL, Taylor ML, Comans TA, Smith AC, Gray LC, Caffery LJ. Determining if telehealth can reduce health system costs: scoping review. Journal of medical Internet research. 2020 Oct 19;22(10):e17298.

Optimising Virtual Care services

Several important factors when considering virtual care include:

• Clinical suitability of condition being treated, including requirements for monitoring and ‘hands on’ assessment.
• Consumer appropriateness and acceptance - ability to effectively utilise and access treatment through modality.
• Escalation pathways have been mapped and planned for in the event that the treatment plan requires escalation for alternate care.
• Supporting equity of access and taking into consideration geography, CALD, disability, cultural safety and socio-economic factors.
• Availability to required technology, infrastructure, and connectivity is validated prior to service delivery.
• Privacy and security considerations including cyber-security, physical safety and privacy of the space the treatment is occurring in.
• Opportunity for improved clinical outcomes through earlier access to care, monitoring and management.

Victorian context

Over the past five years, the Victorian Government has encouraged health services and providers to implement and upscale virtual care through project funding and provision of a state-wide video consulting platform.

Disruptions to usual practice brought on by the COVID-19 pandemic, including physical distancing requirements coupled with enabling funding changes (i.e., the Commonwealth introduction of temporary COVID-19 telehealth MBS item numbers for telehealth) have rapidly increased the use of virtual care.

Virtual care has been successfully adopted by metropolitan, regional and rural clinicians in a range of care settings, including hospitals, aged care, primary care, mental health and community-based care.

Longstanding service delivery models such as Better at Home and new models such as COVID- Positive Care Pathways and the Victorian Virtual Emergency Department have shown rapid adoption of virtual care as a modality for care delivery. These changes demonstrate capacity for a major system transformation in the way care can be delivered.

While the pandemic has served as an unexpected catalyst for change, a continued concerted effort across the health system is needed to embed these changes into routine practice.

The Operational Framework aligns with several key documents including:

• Victoria’s digital health roadmap
• National Safety and Quality Digital Mental Health Standards
• Virtual Care standard and guide

Virtual Care Core Principles

The Core Principles (Appendix 2) outline a systematic and coordinated process for virtual care prioritisation, validation, extension, and safe operation.

1. Clinical governance: A strong organisation and clinical governance framework must be in place to ensure safety and efficacy of care, and to identify when virtual care is appropriate.
2. Safety and efficacy of virtual care is confirmed and safeguarded: The replacement of in-person care should not promote low value care (e.g., where not indicated by evidence or where duplicative) or worse health outcomes.
3. Physiological assessment and monitoring: Where episodes of virtual care require remote monitoring, appropriate and validated tools are used, and patient and care orientation is embedded.
4. Standardised and secure service: Health services should implement virtual care service using ICT platforms that conform with health care standards, guidelines, and frameworks.
5. Complementary tool or value-add: Virtual care substitutes or expands the health care patients can receive in their preferred location of care.
6. Patient first: Place the patient at the centre of care models and support the patient to achieve best possible health Virtual care models should consider the needs of lower socio-economic and vulnerable groups.
7. Workforce capability: Ensure that virtual care augments the clinicians’ capacity and capability to provide high quality and safe care.
8. Service catchment and interaction across the health system: It is important for health services to establish early how virtual care models are provided and the reach and scale of their service provision.

Roles and responsibilities

• The Department provides direction for virtual care via Victoria’s digital health roadmap. The Roadmap, outlines the Virtual Care program and aims to improve the safety and efficiency of Victoria’s healthcare system. The policy and funding guidelines for health services provide direction to Victorian public health services on measurement and reporting of virtual care activity to the department.
• Victorian public health services, community health services, mental health services, primary care providers, Aboriginal Community Controlled Health Organisations (ACCHOs), and Primary Care networks, provide and/or support the community to access to virtual care.
• Consumers, (and their families, and carers) of Victorian healthcare services, are key recipients of virtual care services provide advice and input, especially around experience.
• Third party providers such as videoconferencing platforms, electronic medical record platforms, integration vendors and telecommunications providers, develop and deliver virtual care platform technology.

Additional key stakeholders involved in planning, implementing, support and monitoring the provision of virtual care in Victoria include:

• The Federal Government through sustainable (MBS) and innovation and project
• Regulators and those responsible for developing guidelines and standards such as:
  • Australian Health Practitioner Regulation Agency (AHPRA)
  • Australian Digital Health Agency (ADHA)
  • Australian Commission on Safety and Quality in Health Care (ACSQHC)
  • Safer Care Victoria (SCV)

The Victorian Virtual Care Operational Framework is comprised six (6) core elements for the safe operation and extension of virtual care services across the Victorian Public Health Sector. All virtual care services should address these elements to establish, operate and improve:

1. Clinical governance
2. Digital technology
3. Consumer centeredness
4. Digitally capable workforce
5. Service delivery and equity
6. Evaluation and continuous improvement

This tool can be used as a guide to develop an approach to offering virtual care services whether as a new service or to assess an existing service.

There are two categories. Assessing the program and operational framework. All Victorian Health Services may not meet each of the elements outlined in the checklist. However, it should not act as a barrier to implementing virtual care.

Assessing the Virtual Care service

Operational Framework elements

Clinical Governance

Corporate Governance

Ensure organisation has a fully integrated corporate governance model in place that includes clinical, risk, financial and other governance

Clinical Governance

Ensure strong clinical governance model aligned with National Safety and Quality Health Service (NSQHS) Standards.

Authorising Environment

Ensure all virtual care service provision has been endorsed by health service through Health Service approval mechanisms.

Digital technology

Standardisation

Use ICT platforms that conform with accredited standards, guidelines, and frameworks.

Authentication

Non-authorised participants should not have access to the virtual care appointment or participate on the consultation.

Localised Platform

The Digital Transformation Agency’s (DTA) Hosting Certification Framework governs public sector data and requires all data to be stored onshore.

Workflow Integration

Optimise patient care through use of digital technology that integrates into and complements clinical workflows.

Technology governance

Incorporate effective implementation methodologies and change/release communication, training for digital health applications and oversight of technology decisions via appropriate governance mechanisms.

Partnering with consumers

Consumers of program

Virtual care service delivery should incorporate the development of an engagement plan to ensure consumer voice is recognised and health services are demonstrating responsiveness to the needs of the patients and the communities they serve.

Complementary tool or value-add

Consider alternatives to providing services exclusively through virtual care if the patient preference is for face-to-face consultations or if provision of services virtually is not the most appropriate method for health care delivery. Consumers should be involved in discussions about the appropriate modality of care and their right to choose must be respected.

Patient feedback

Ensure patient feedback is sought in an inclusive and culturally appropriate way and considered in future development. Consider systems for collecting and monitoring patient-reported experiences, outcomes and are considered to be used in the design of services that incorporate virtual care.

Privacy and confidentiality

Virtual care service delivery must adhere to privacy, data sovereignty and confidentiality obligations.

Digitally capable workforce

Workforce requirements

Development of virtual care guidelines regarding service providers expected skills, behaviour and guidelines

Capability building

Provision of resources (including access to education, training and/or mentorship) to enable skill development

Access and equity

Equity and access

Ensure that local health service policies and infrastructure promote equitable access to virtual care services. Consideration of cultural, socio-economic, digital literacy and technological inequities should be incorporated in strategies and service delivery plans.

Aboriginal and Torres Strait Islander cultural safety

Create an environment that is safe for Aboriginal and Torres Strait Islander people, based on shared respect, meaning and knowledge. Ensure design, delivery and evaluation of virtual care models support self-determination for Aboriginal people.

Service delivery and scope

Consideration of service delivery mechanism of virtual care e.g. whether standalone session or integrated into an existing clinic. Identification of which patients are in and out of scope for virtual care.

Clinical and data workflows

Prior to implementation of virtual care service delivery, clinical and data workflows are mapped, and any differential requirements addressed to ensure that optimal service delivery is achieved.

Reporting and funding

All virtual activity needs to be reported accurately to the Department of Health to ensure it is counted. Funding for virtual activity is either on an activity (NWAU) basis or through specific funding arrangements. Information regarding the requirements can be found in the Policy and funding guidelines for health services.

Evaluation and continuous improvement

Initiation and scaling of new models

New virtual care models are scaled with a plan to evaluate the benefits and harms, including (if applicable) the collection of data and qualitative insight from consumers and staff, taking into consideration the importance of data sovereignty.

Regular performance review

The health service commits to submit timely and accurate data to the Department as per existing and new state-wide performance monitoring.

The performance of virtual models of care delivered through partnered health services are reviewed collectively between those participating in delivery.

Timely review of adverse events

In the event of an adverse event (including mortality, morbidity, delayed care and access barriers), cases are referred dedicated committee for clinical review and action.

Accreditation

Virtual care models adhere to quality and safety standards recognised by the Department of Health Victoria.

The Core Principles are systematic and coordinated principles to guide virtual care prioritisation, validation, extension, and safe operation.

1. Clinical governance

To ensure safety and efficacy of care. A strong organisational and clinical governance framework must be in place to help clinicians:

• identify when virtual care is appropriate for patient consultation;
• fulfil compliance obligations by regularly reviewing and reporting best practice principles; and
• ensure that it does not deviate from existing clinical care standards (such as the National Safety and Quality Health Service Standards), policies, guidelines and directives.

This is to enable high quality care, and sound decision making.

2. The safety and efficacy of virtual care must be confirmed and safeguarded

The replacement of in-person care should not promote low value care or worse health outcomes. Escalation triggers and protocols for deteriorating patients are part of each virtual care cohort and model.

3. Physiological assessment and monitoring

Where patient triage, assessment and diagnosis require physiological assessment and episodes of virtual care require physiological monitoring, appropriate and validated tools are used, patient and carer orientation are embedded and patient choice respected.

4. Standardised and secure service

Health services should implement virtual care service using ICT platforms that conform with health care standards, guidelines, and frameworks. Only authenticated patients and health service providers can use the service. ICT services and infrastructure must comply with Australian Signals Directorate requirements. Patient information and metadata are not managed offshore.

5. Complementary tool or value add

Virtual care substitutes or expands the health care patients can receive in their preferred location of care. Health services provide alternatives to virtual care if the patient preference is for face-to-face consultations, or if provision of services virtually is not the most appropriate method for health care delivery, particularly when considering complex and vulnerable patients.

6. ‘Patient first’

Support the patient to achieve the best possible health outcomes. Place the patient at the centre of this arrangement, not the technology, platform, or other potential players. Consumer representatives should be consulted in the development of virtual care services and care models should keep in mind digital equity for patients who may otherwise not be getting the care they need.

7. Workforce capability

Ensure that virtual care augments clinicians’ capacity and capability to provide high quality and safe care. Multidisciplinary teams need to be competent in virtual care provision to achieve better clinician experiences and patient outcomes in the health journey.

8. Service catchment and Interaction across the health system

It is important for health services to establish early:

• how their virtual care models are provided (e.g., such as partnerships with trusted vendors) and;
• the reach and scale of their virtual care service provision (e.g., part of a regional, state or national network).

On defining each virtual care model, health services apply existing standards to inform service and technology design, expectations for patient and provider conduct, and clinical workflows.