When asked to describe their role, only four participants spontaneously discussed eHealth as part of their practice, and three spoke exclusively about the use of telehealth. Even when prompted to consider other eHealth technologies, such as telephone applications and online programs, participants tended to focus on telehealth as the main form of eHealth used in their practice. Further, the use of telehealth was primarily discussed in the context of an emergency response to the COVID-19 pandemic rather than as a standard practice approach implemented under non-pandemic conditions.
A sense of safety and control — ‘it puts the care back into the control of the consumer’
Healthcare professionals in this study observed that being able to access telehealth from the comfort of their own home gave some clients a greater sense of safety, as “they’re able to be in their own space where they probably feel more safe” and they “don’t need to look someone in the eye or feel awkward.” One participant noted that this sense of safety facilitated greater openness bAy her clients, enabling them to “say what they really felt”. However, participants also expressed concern about the use of eHealth with cQlients whose home environment is unsafe, as online or telephone consultations do not always afford the “privacy to be able to have the conversations that [clients] wanted to be having.”
Several participants observed that telehealth increased clients’ control over the healthcare interaction, allowing them to decide “whether they hang up or not, rather than needing to walk out of a room or leave a space”. In particular, digital health interventions in the form of apps gave clients more control over the recovery process, enabling them to access care when and how they most needed it:
"eHealth puts the care back into the control of the consumer. So rather than waiting for the next psychology appointment or anything like that, it allows the recovery process to be back, a little bit more in control of when the consumer needs it and they can then direct either how quickly they might do a module through an app, or whether there’s a mindfulness practice that they grab off a different app and they can do that when they actually need it in live time."
In contrast, health professionals experienced a loss of control when using eHealth technologies which, for some, resulted in a feeling of discomfort:
"You then realise like wow we really want control. We want to make sure that we can be there, and we can support you, and we think that that can only happen that [one] way"
Several participants described the sense of unease created by the disruption to standard clinical procedures and therapeutic approaches during the rapid and “forced” implementation of eHealth during COVID-19. One participant noted that her clinical colleagues “didn’t feel like their assessments were a true reflection of what was happening”. In fact, some healthcare professionals who were working with “the most unwell people in our community” “refused to do initial assessments [using telehealth] because of the concerns about missing something”. One participant observed that the level of resistance to eHealth is dependent on the perceived risks it poses to quality of the healthcare assessment:
"I think there’s probably more resistance for different people, different teams depending on their comfortability [sic] with technology or the risk that they might perceive might happen by missing something if you’re not in the room"
Expanding the breadth of care — ‘the stuff in between’
Healthcare professionals in this study observed that the “flexibility” and “convenience” of eHealth technologies enabled them to “reach out to a much larger audience” and facilitate participation by people who may not otherwise have access to healthcare services:
"So, they don’t have to be in the clinical space in a particular space to participate in the traditional health service or any discussion, they can be anywhere and that gives a chance for a larger group of people to participate. And the feeling to participate I think as well."
Participants observed that eHealth is most likely to facilitate broad participation and inclusion when it is “adapted to different groups of consumers…whether that’s differences in gender or age or culture or, yeah, or what that person’s actually experiencing”. Where an eHealth tool was recommended by health professionals, but did not meet the needs of clients, participants noted that “[clients] deleted it from their phones because they never use it”. For example, one participant noted that an app had been rolled out across their clinic but had been deleted by “over half of patients” because they “don’t want it”. The same participant acknowledged that, while client interest in eHealth apps is important, also crucial is that clinicians are “invested in it” and “think it works”.
Several participants acknowledged that “clinicians are only available between certain times during the day” and that “concerns about mental health and low moods don’t stop at 4:30”, noting that “some sort of [eHealth] support could be really important at these times”. These participants tended to view eHealth as “the stuff in between” more traditional forms of healthcare provision, rather than as a standalone form of care.
Resources and capacity — ‘it’s kind of dependent on someone’s resources’
A key finding from this study was that clients’ engagement with eHealth tools is often impacted by a lack of resources. Participants noted that “many people don’t have computers and laptops and things like that in their home” or may have difficulty maintaining “consistent” internet or phone access as “they may not pay their phone bill all the time”. Even when clients are more financially stable, spending money on eHealth technologies “may not necessarily be a priority” for them. Consequently, one participant noted that “if you want to make [eHealth] broadly available to patients, it’s got to be free.”
A lack of capacity and technological literacy were also highlighted as key barriers to the uptake of eHealth by clients. As one health professional noted:
"A lot of our clients, they lose their phones, or they break their phones, or they just don’t have the capacity, or sometimes they just don’t have that understanding how technology works."
Several participants observed that “the most marginalised people in our community” (i.e., those from “lower socioeconomic backgrounds and with the lowest IT literacy”) are also the most likely to experience difficulties in accessing eHealth tools. Participants perceived multiple, often intersecting, barriers that impacted on their clients’ access to eHealth, including cognitive ability, mental illness, and literacy. As one participant summarised:
"The more unwell someone is, the more challenges they have in accessing eHealth options. I think just the processes involved in maintaining a mobile phone account can be really difficult."
Participants also emphasised the lack of support available to help clients engage with eHealth tools:
"We’ve been provided with support and training in how to document, set up Skype, use Skype and troubleshoot stuff. Whereas when we call clients, it’s like, all right, we’re going to send you a link. If it doesn’t work, that’s it – there’s no troubleshooting support for them."
Some health professionals tried to address this issue by providing technical support to clients themselves, which led to a significant increase in their own workload:
"The biggest workload for our team involved setting up clients in being able to access telehealth. Having a social worker and/or nurse joining a doctor for those three clinics was about just getting clients to the appointments. So, we did a lot of phone calls leading up the appointment."
A fundamental shift— ‘it does require the practitioner to try a whole new mode’
Overall, healthcare professionals recognised the need for healthcare services to embrace technology as “the way of the future”:
"I mean we’re living in a technology world aren’t we so we’re going to have to progress."
However, a number of participants described feelings of “hesitancy”, “scepticism” and “discomfort” in relation to eHealth, questioning whether “it could be equivalent or better than meeting face to face.” Participants who expressed these sentiments tended to describe eHealth as an insufficient ‘replacement’ of face-to-face practice:
"I mean we’ve had telehealth for many years, but health professionals are sceptical that it could be equivalent or better than meeting face to face."
For example, in describing her hesitancy to integrate eHealth into her practice, one participant expressed a concern about losing a valued aspect of her practice:
"I really value the face-to-face aspect of getting to know someone. I’ve been a bit hesitant, I guess, to introduce eHealth to my practice."
Another participant described eHealth as disrupting the “etiquette” and “seriousness” of healthcare provision:
"I think the families are not taking it serious enough, so that lack of etiquette, like walking into the teenager’s bedroom carrying the phone, and waking the kids up in bed, or the kids aren’t even there, the kids are playing outside. Yeah. Not having the gear uploaded, like not taking it as seriously as if they came to the clinic."
When discussing her colleagues’ scepticism about eHealth, one participant noted that the use of eHealth requires a fundamental shift in the way healthcare professionals engage and interact with clients:
"They’re sceptical about the technology. I think it you know, it does, you know, require the practitioner to try a whole new mode of speaking with people and learning that technology, even though it’s not that complicated."
This participant concluded that “I guess they’re sceptical [because] I think they feel really uncomfortable not being able to have full verbal and non-verbal communication.” However, some participants also described positive experiences using eHealth, and emphasised the benefits of this mode of delivery for their clients:
"Some clinicians did feel like the [telehealth] service offered during COVID was more superficial in terms of the intervention you could do because the person might be distracted. I haven’t found that myself. The clients I have worked with, as I said, it kind of has worked in their favour and even if there has been challenges in the environment they do try to manage those so they can be present."
These participants often recounted aspects of eHealth that were “different”, but that extended their practice or even made it more “powerful”:
"There can be opportunities to learn about your patient too. When you see them in their home it’s different to seeing them in the room…you get a bit of an insight into their life or what they’re interested in. So, you also learn about them more."
"Sometimes the phone can be more, I can feel more connected because I’m not distracted, I mean I’m looking for an emotional assessment, the assessment of their emotional state as well as a connection, sometimes the phone can be even a bit more powerful in that way."