Introduction

In recent years there has been a rapid global expansion of virtual hospitals, virtual wards, and hospital in the home services, with all models offering care to patients outside the traditional hospital settings, henceforth referred to collectively as “virtual hospitals” 2,3. Virtual hospitals offer hospital-equivalent healthcare in a patient’s home or community3. Research evidence is critical to inform healthcare decision makers considering implementing a virtual hospital. However, although there is strong evidence for the safety and clinical effectiveness of virtual hospitals1,3,4,5, implementation research has lagged4,5. Research guiding the implementation of virtual hospitals is not advancing at the same rate as actual virtual hospital implementation. Furthermore, existing studies are heterogenous in terms of population groups, sample size, models, outcome measures and even modality (for example telehealth care versus telemonitoring)3. There is substantial variance between models of care described as virtual hospitals, and little guidance on selection or design of a suitable model of care for various healthcare settings and needs. There is acknowledgement in the literature that implementation of many virtual hospitals has been rushed in the context of the COVID-19 pandemic6,7,8. One study described setting up a COVID-19 virtual ward as being like building a plane while flying it6. Consequently, the majority of existing implementation literature has been retrospective and reliant on participant reflections.4.

Of the few published pre-implementation studies9,10,11, only one reported a collaborative design process10, and none used authentic consumer-inclusive co-design methods. Co-design in healthcare brings together health consumers and other stakeholders such as clinicians, healthcare executives/decision makers, informal/family carers, community and government representatives to develop solutions to complex healthcare problems12,13,14. Typically the goal or problem is pre-defined, and stakeholders come together through a range of methods to provide input and ideally agree on solutions. These collaborative processes aim to design healthcare services that are fit-for-purpose for consumers and healthcare providers alike, enable knowledge mobilisation, and reduce research waste13,15,16. Although Dinesen et al.10 described using a pre-implementation ‘design panel’ of clinicians to guide workflows and clinical processes of a hospital-in-the-home, no consumer or carer involvement was reported.

One previous grey literature virtual hospital co-design study was identified17 My Home Hospital in South Australia used a co-design process to develop a clinical pathway and patient journey prior to commencement of a public hospital-in-the-home service. No research that addressed the development of a long-term vision or overarching principles of a virtual hospital was identified. Having a clear set of principles is an integral component of virtual hospital design according to healthcare stakeholders17,18.

This research aimed to inform the design of a new private Australian virtual hospital by: (1) understanding the virtual healthcare needs, preferences and perspectives of a broad range of stakeholders; and (2) agreeing upon themes to inform a shared set of principles.

Methods

We conducted a qualitative pre-implementation co-design study in July-Sep 2023 which involved three workshops with key stakeholders, one face-to-face in Brisbane, Queensland and two online. This study was the second phase of a research program to inform the design and implementation of a private Australian virtual hospital. The first phase was a context assessment to determine contextual barriers and enablers to implementation. The context assessment results and additional information about the theoretical approach used are reported elsewhere18. This manuscript reports results of the co-design workshops only. This research was informed by the Planning and Evaluating Remote Consultation Services (PERCS) implementation science framework19. PERCS was developed during the COVID-19 pandemic to inform the rapid roll-out of virtual consultations in the United Kingdom’s National Health Service. It provides an evidence- and theory-based conceptual framework and guidance on stakeholders that need to be considered in the planning for remote consultation services. The first phase of this research18 used PERCS throughout, in the development of the interview guide, framework analysis, and reporting of results. This study built upon the phase one findings, and although it wasn’t explicitly used in the analysis or reporting, the interpretation of the results was informed by PERCS constructs and how these influence virtual healthcare.

Objectives.

  1. 1.

    To identify and agree upon components (themes) of a ten-year vision to inform ongoing design and development of the virtual hospital.

  2. 2.

    To identify and agree upon recommended principles for the virtual hospital.

Co-design process

Three workshops were conducted. Each workshop was audio recorded. The face-to-face workshop was two hours, and the two online workshops were 90 min. Participants were informed that they were welcome to provide additional written feedback by email in the two weeks following the workshop. Each workshop consisted of a series of activities in the full group, and in small focus groups. Each focus groups was facilitated by a member of the research team to ensure that conversations remained focused on the research question and all participants had the opportunity to share their perspectives. Participants attended one workshop only and were not informed of the results of previous workshops. To minimise the potential impact of any imbalance of power between participants, e.g., a health consumer and a doctor in the same focus group, the activities involved both group discussions and opportunities to provide individual and anonymous feedback. Focus group membership was allocated by the workshop facilitator to minimise the impact of predictable power dynamic issues, e.g., no participant was allocated to a focus group with their line manager. Workshop activities:

  1. 1.

    Critique and confirmation of the context assessment results. Each workshop commenced with a presentation of context assessment results, followed by a whole-of-workshop group activity to critique and/or confirm the results. A summary of the responses was written on a whiteboard by the workshop facilitator and participants had the opportunity to provide clarification or correction of the summarised findings.

  2. 2.

    Critique of the draft principles. A draft set of principles for a potential virtual hospital derived from the context assessment results were presented (Supplementary File A – Draft Principles). Participants were split into focus groups of between three to six people, each with a facilitator from the research team, to critique the drafts. Each focus group then provided feedback to the whole-of-workshop group, which was summarised on a white board by the workshop facilitator. The summary was checked and clarified with participants during the discussion.

  3. 3.

    Development of next steps. Participants were asked to consider the tasks/steps required to reach the vision within ten years. Steps were developed individually and shared anonymously by either (1) using post-it notes placed along a timeline in the face-to-face workshop; or (2) on a shared OneDrive file with a ten-year timeline which all participants were able to edit anonymously during the online workshops.

Participants

Purposeful selection was used to identify participants. All participants of a phase one interview (n = 37) were invited to a workshop unless they had previously expressed that they were not interested in attending a workshop (n = 1). Additional stakeholders who had not been interviewed were identified by the research team using a snowball sampling strategy. The focus of selecting types and numbers of participants ensured representation of key stakeholder groups and roles, as outlined in results Table 1. Therefore, representation of participants was prioritised over data saturation.

Table 1 Workshop participants.
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Qualitative analysis

Following each workshop the research team conducted a one-hour debrief session to discuss initial impressions, emerging themes, reflections on engagement and participation, and any necessary process-related adaptations for future workshops. These debrief sessions were recorded and transcribed and formed part of the analysis process. The three co-design workshops were fundamental in enabling participants to finalise the themes and therefore the underpinning principles of the virtual hospital.

Because of the value of inductive coding, we chose to use a pragmatic thematic coding methodology where we coded point (topic) by point, not line by line20. In this way, we were able to develop descriptive codes and themes that accurately represented the data, within the health service’s required timeframe. OF and BM coded all workshop transcripts, and regular discussions were held with CG to agree on and confirm the descriptive codes and themes. Discussions included comparing and examining codes, and reaching agreement on any differences. Descriptive codes and themes were then compared with the debrief session transcripts to ensure alignment. The themes and codes in our results shaped the final vision and principles leveraged from Workshop Activity 2 data: Critique of draft principles.

Data storage

All electronic data were stored on secure password-protected servers managed by the research institute, and paper-based data were stored in a locked file storage in a secure swipe-card access facility. Data management and retention complies with Australia’s National Health and Medical Research Council’s Management of Data and Information in Research guide.

Ethical considerations and approval

Informed verbal consent was obtained from all participants at the commencement of each workshop. Written consent was not obtained. These methods were approved by the UnitingCare Queensland Human Research Ethics Committee. To avoid any potential perception of coercion to participate, consent was obtained by a member of the research team who did not have any supervisory relationship with the participant. To address any potential influence that imbalance of power between group members might have on participant responses during the workshop the activities included opportunities to provide feedback in small, facilitated focus groups, in the whole group, and individually. There was also an option to provide written feedback directly to the research team following the workshop. Ethical approval was received on 9 January 2023 from the UnitingCare Queensland Human Research Ethics Committee, Reference: Fisher_20221207. All methods were performed in accordance with the relevant guidelines and regulations.

Results

Participants

Eight focus groups were facilitated across the three workshops. The majority of participants (n = 26, 72.22%) attended an online workshop, with three (8.33%) attending from outside of a metropolitan area (Table 1). One participant provided additional written background information in the week following the workshop by email.

Themes and subthemes

No participant identifiers have been included for workshop quotes because it was not possible to accurately identify each participant from the audio recordings due to the large size of some groups. Participants confirmed the considerations, enablers and barriers identified in the context assessment. There was strong alignment in responses across the three workshops, with the exception of a greater focus on rural and remote issues in the online workshops. Participants were enthusiastic about the potential of the virtual hospital and stated that they appreciated the opportunity to provide input on the vision and principles from their perspectives. Across the three workshops, the following overarching themes and sub-themes emerged:

Theme One: Take the care to the patient

Workshop participants reported that the major advantage of a virtual hospital, as opposed to care provided in a physical hospital, is that patients can receive hospital care in their own homes, avoiding unnecessary travel and time away from their communities. The ability to provide hospital-level care regardless of location was seen to open opportunities to address critical healthcare needs in Australia, such as the lack of access to private and tertiary hospitals in rural and remote Australia. However, challenges were identified such as potential consumer reticence to use new models of care, and the ability to provide culturally appropriate care to a population as diverse as Australia’s. Providing care in the patient’s location as opposed to a traditional hospital also raises issues around communication with other health and emergency services providers while a patient is admitted to a virtual hospital. Theme One then informed the key principle of being patient centred, as displayed in Fig. 1.

Sub-themes

  1. 1.

    Create and address demand for timely healthcare ‘in place’: Customers and patients are beginning to expect convenient and timely virtual health services, which are accessible in their own homes or communities – i.e., ‘in place’. However, it was acknowledged by participants that work is needed to effectively build familiarity with and greater demand for these ‘in place’ services in the general population. Younger people were seen as central to developing this demand within the community.

One of the questions that I would love answered is, ‘if you could have your care episode… at home… do you think you would take advantage of that?’ Because I found that most people haven’t even thought about it… It doesn’t occur to the clinicians, and it doesn’t occur to the to the patients or carers either. And it doesn’t need to be in their own home, it could be in their daughter’s home or their son’s home or their parent’s home. And it’s just sort of and thinking about and, and if that had to happen, what would need to be in place for that?

  1. b.

    Removing geographical boundaries: There was strong support for provision of virtual hospital services to rural and remote areas.

  2. c.

    Inclusive and appropriate: Australia is a diverse country, and the needs in one location are not representative of the needs across the whole country. Patients require services that are culturally appropriate, accessible and inclusive for people from diverse backgrounds. Expanding the geographical location increases the diversity, hence the complexity, of inclusive and appropriate care provision.

  3. d.

    Support the transition between services: In a traditional hospital, if a patient required immediate care they would likely be transferred to another ward or service within the same hospital. However, for a virtual hospital, if a patient requires face-to-face assessment or intervention they may need to attend other local providers such as a public hospital or general practitioner. Patients frequently transition between public and private healthcare providers, ambulance, general practice, and aged care providers. This means real-time communication between services will be critical to smooth patient transitions. Currently, there is a lack of streamlined communication between services to enable smooth transitions, which can be challenging for both patients and carers, and providers. Improving transitions through care navigation or more effective communication strategies is important.

And I would like to think that we would be partnering with public hospitals or statewide systems working that, that we know patients do flit from public to private and that they would need a system in place where the virtual records would be accessible by all.

Theme two: virtual is the mechanism, the care is real

Participants felt strongly that virtual healthcare must be of equivalent safety and quality to face-to-face healthcare. The ability to develop trusting relationships between providers and patients was seen as critical, and there was variance in responses about whether this is possible via telehealth. However, concerns were raised about the language of “virtual” care referring to something that is not quite real, or not as good as traditional care. Advantages and disadvantages to using virtual mechanisms were raised. Virtual care was seen as potentially substandard care when compared with traditional consultations involving, for example, “healing touch”, but as technology is developed, virtual care was seen as potentially superior to traditional models, e.g., improving accuracy of clinical monitoring and assessment. Theme Two informed the second principle that a Virtual Hospital needs to be more than just telehealth (see Fig. 1).

Subthemes

  1. 1.

    Less than a physical hospital: There was a perception from some participants that the term “virtual” indicated that the care was not “real,” raising the question of whether the language of “virtual hospital” may need to be amended. There was a lack of agreement on this point. Participants, particularly in the first workshop, discussed alternative language to “virtual” but no appropriate alternative was identified, therefore participants felt that it was important to define virtual as the mechanism through which care is provided. Concerns about the need for physical examination were raised. The importance of supportive physical touch as part of a healthcare consultation was raised, and some participants believed that this was a major limitation of telehealth.

Personally, I have a very different feeling with the word virtual. The feeling I get is ‘not real’.

  1. b.

    Better than a physical hospital: Rapidly advancing technology is opening opportunities for monitoring that is likely to be more accurate and potentially faster at detecting changes in patients’ clinical presentation than previously possible. “Hospitals harm people” was a consistent message in both the context assessment and co-design studies. Hospital acquired infection was a major concern raised about traditional hospitals, as well as difficulties for some patients in adapting to a ward environment, e.g., patients with dementia, which can result in confusion, falls, and other adverse outcomes.

We know for many reasons it’s safer from the infection perspective and a number of other things, they are with family, they [family] can provide care, but they [patients] really need… the input of their doctor.

Participants felt that younger people adapt more easily to new technologies and are less likely to see virtual healthcare as inferior to face-to-face. Younger people were described as easily forming relationships with people online, without the need for face-to-face contact.

Theme three: be ambitious, but build a strong foundation

The need to build a strong foundation for the hospital was a strong theme, particularly relating to safety, procedures, clinical governance, and appropriate technology. These foundational elements were seen as required precursors to any new services. There was consensus that participants wanted virtual hospital leadership to ‘think big’ and be ambitious to include a broad variety of healthcare services in a virtual hospital, similar to what they would typically access at a traditional hospital – which goes beyond just acute inpatient services. There was agreement that an ambitious vision needed to be rolled out slowly over time, using a phased approach, careful planning, and evaluation of cost effectiveness. Underpinning all principles for the virtual hospital was therefore ‘Safety’. The importance of having technology and models of care that were ‘Adaptable’, reliable and user friendly was also emphasised (see Fig. 1).

Subthemes

  1. 1.

    Safety first: This was one of the strongest messages from the co-design workshops. Safe care was seen as separate to high-quality care, and both were considered necessary.

  2. 2.

    Technology that’s fit for purpose: Participants raised the need for technology that is:

  • Easily adaptable to incorporate new services and technologies as they are developed.

  • Reliable.

  • Affordable for both the health service and the patient.

  • Able to integrate with other existing systems.

  • Easy to use, both for providers and consumers/carers.

  • Trained with First Nations and diverse voices.

“Everybody in our [focus] group has had the experience of having programs that don’t talk to each other, unstable platform that we’re managing programs on that we-, you know, program falling over, IT not being in a stable environment, programs going down, no accessibility.”

  1. c.

    More than just acute care: Participants were enthusiastic about the possibility of providing comprehensive care to patients, including acute, sub-acute, proactive and rehabilitation services via the virtual hospital.

  2. d.

    Must be cost-effective: Both for the healthcare provider and for patients. Participants described advantages to patients such as reduced travel time and expenses, as well as additional costs to informal carers such as time off work or away from usual tasks to support a virtual hospital patient.

Theme four: build the right workforce

The “right” workforce was described as one that is comfortable with technology, able to take on the responsibility of autonomous patient care, and ideally co-located to encourage interdisciplinary collaboration, effective communication, and planning. Although there are workforce issues across Australia that create challenges for all healthcare providers, virtual hospitals were seen as providing an opportunity to potentially re-engage a workforce of experienced clinicians who had left healthcare, e.g., due to injury. The right workforce was also seen to include informal/ family carers, who may experience an increased burden while supporting a virtual hospital patient, e.g., the potential need to take time off work. The responsibility and burden for some aspects of patient care potentially shifts from the healthcare provider to the informal carer. This theme informed the principle of being ‘Innovative’, offering flexible work options to grow the workforce (see Fig. 1).

Subthemes

  1. 1.

    Workforce opportunities: For health professionals who have barriers to being able to provide face-to-face care e.g., due to injury, a virtual hospital may be an opportunity to enter, extend or patch their healthcare career. The flexibility that virtual healthcare offers providers was seen as an important advantage to attract a high-quality workforce.

  2. 2.

    Informal carers are a critical workforce: Participants felt that without the important contribution of informal carers supporting patients at home during the admission the virtual hospital would not be viable. Participants therefore felt that the increased burden of care and responsibility on carers was important to consider, including the potential emotional toll of taking on a role that may require monitoring and escalation if a patient’s health declines.

"You’re taking the work that would normally done by the health care system and requiring the carers to do it. And we need to be immensely aware of the personal cost… Often that’s not accounted for in business statements and financial assessments… it takes you out of workforce and other activities in your life, whether they’re volunteering, caring for children or other activities".

Principles

Both “patient centred” and “safety first” were raised by the majority of focus groups as the key principles for the virtual hospital and this was confirmed in in all three workshops. The opportunity to provide truly patient-centred care in their own home environment or community was considered a distinct advantage of virtual healthcare. Through collaborative discussions, the groups identified that “safety first” needed to underpin all principles, rather than being a standalone principle, leaving “patient centred” as the highest priority principle (see Fig. 1). Figure 1 details the Principles for a virtual hospital. The first panel highlights Patient Centred Care, the second More than Telehealth, the third Adaptable and the fourth Innovative.

Fig. 1
Fig. 1The alternative text for this image may have been generated using AI.
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Final Principles for the Virtual Hospital.

Discussion

Four overarching themes and five principles were identified. Themes were: (1) take the care to the patient; (2) virtual is the mechanism, the care is real; (3) be ambitious but build a strong foundation; and (4) build the right workforce. Principles were informed by the data analysis and identification of themes: a virtual hospital needs to be Patient Centred - being culturally appropriate and high quality; More than Telehealth; Adaptable; Innovative; and underpinned by being Safe for patients, their families and carers, and staff. There was strong alignment on principles and themes across the focus groups within each workshop, and across the three workshops. The main area of difference between participants was the varied perspectives on the advantages and disadvantages of a virtual hospital compared with traditional hospitals. Using a co-design approach created enthusiasm and buy-in from the invited stakeholders, who were able to express and discuss their ideas, concerns, and considerations. The robust discussions between varied stakeholders in the workshops meant that a diverse range of perspectives were voiced and represented in these final data. Participants only attended one workshop and were unaware of the responses of participants in previous workshops. Despite their different backgrounds, participants returned to the same four themes in all three workshops. ‘Patient centred care’ and ‘safety first’ were both considered fundamental principles, which aligned with the results of the context assessment study18. This aligns with previous research where patient centred and safe care is paramount to hospital at home initiatives4.

There is a need for clear definitions of “virtual hospitals” and “virtual healthcare.” This study found participants, especially in the first workshop discussed the use of the term virtual hospital and the various meanings attributed to the word virtual. No alternate term was forthcoming so the term virtual was still used. This issue was also reported in previous studies where participants were hesitant about a model because of their assumptions around the terminology used17. Similarly, a United Kingdom study highlighted there is a range of terminology used in practice, from hospital at home, virtual wards, remote monitoring, step-up or step-down models of care and the interconnection and overlap of these can create confusion2. The use of terms and clarifying meaning is important for future studies.

Co-design offers a way to collaborate with healthcare professionals to develop appropriate solutions to health service and system issues12,13,14. By integrating the experiences and perspective of stakeholders, co-design strengthens healthcare systems and creates patient centred and evidence based solutions12. Engaging with a range of participants, has been shown to create a better fit-for-purpose healthcare service leading to improved outcomes13. We, therefore, used co-design to hear from a range of participants and perspectives about virtual hospitals. We acknowledge that codesign will not inherently solve issues. Solutions need to be context-informed, acknowledging wider factors including social, political and economic that may or may not be discussed during co-design processes12. One of these wider factors is the possible legal implications of the communication of healthcare information and the risks of cyber-attacks on patients’ personal information. Further research about the legislative environment is needed to uphold the foundational principle of being patient centred and safe for patients. The need for interconnectivity across platforms to communicate safely, effectively and efficiently is another area for future research. The implications of creating a digital divide which further disenfranchises vulnerable groups needs consideration8.

This research has also highlighted participants’ concern that virtual hospitals will create further burden on informal carers of potential patients. In South Australia, democracyCo identified that carers wanted to have a meaningful role in patient care, acknowledging how within the traditional hospital setting they feel they do not matter17. Although, they also identified that carers rarely ask for help. Having support through fellow peers or a counsellor (who is separate to the medical care) was recommended.17 The need to prioritise the impact of carer burden and outcomes as a key consideration in evaluations of virtual wards has been highlighted in a recent rapid evidence synthesis. Norman et al.2 identified that carers were sceptical about how viable hospital care at home would be and raised many concerns about practicalities such as home cleanliness17. They also identified benefits including reduced travel time and planning of appointment logistics17 suggesting that there may be a range of barriers to uptake from a carer’s perspective5.

This study is the first pre-implementation study to use co-design in informing the design of a private Australian virtual hospital and establishing a set of shared themes and principles to inform implementation. The study builds on the sparse pre-implementation, virtual hospital studies.establishing a set of shared themes and principes to inform implementation. The study builds on the sparse pre-implementation, virtual hospital studies,9,10,11 and is the first to use authentic co-design methods in a private hospital setting. 4,17 Likewise, the need for simple and reliable technology, and the stakeholder enthusiasm about digital health opportunities aligned with democracy Co’s results. Our research builds on these themes offering further insight into the complexity and considerations to implementing a virtual hospital. Further research is needed to identify whether these results are replicated in other countries and contexts.

Limitations

The scope of this study was to identify an agreed set of principles for the virtual hospital. There was a condensed and restricted timeline for recruitment and data collection. There was a possibility of group think in workshops, although there were break-out sessions which helped mitigate against this. The research team used group allocation strategies and a variety of individual and group activities to minimise the risk of potential power dynamics. Yet, given the broad range of stakeholders it was not possible to identify or mitigate against all perceived and/or actual power dynamics that may have influenced the results. Additional co-design processes will be required to develop new models of care, including a more diverse group of health consumers and carers. Further research will be required to determine whether adaptations to the principles are necessary. This study was conducted in an Australian private not-for-profit healthcare setting which may influence the generalisability of these results. Additional research in other settings is required.

Conclusion

Bringing together health consumers, informal carers, clinicians, healthcare executives, informal carers, researchers, and government stakeholders enabled robust discussion and strong agreement on the major data themes and agreed principles for a private virtual hospital. There was strong alignment of responses between the three workshops indicating good reliability of these results presented in the themes and virtual hospital principles. Authentically patient centred care – “take the care to the patient” – and safety first were the strongest messages across all stakeholder groups.