Preparation and implementation factors in rural healthcare innovation: a mixed methods investigation of a virtual medical officer model of inpatient care in Australia

Preparation and implementation factors in rural healthcare innovation: a mixed methods investigation of a virtual medical officer model of inpatient care in Australia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Preparation and implementation factors in rural healthcare innovation: a mixed methods investigation of a virtual medical officer model of inpatient care in Australia Carol Joy Reid, Catherine Church, Viv Jeffery, Ka Chun Tse, Andrew Freeman, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6166035/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background The connections between preparation and implementation factors when introducing virtual models of care in rural inpatient settings are critical for success but remain unexplored. This evaluative study investigated the introduction of a virtual medical officer innovation in three acute wards of a rural health service in Victoria, Australia. To present novel insights, we examined the results using constructs from two implementation frameworks, the Exploration Preparation, Implementation, Sustainment (EPIS), and the Consolidated Framework Implementation Research (CFIR). To synthesise findings, the Implementation Research Logic Model (IRLM) was utilised. Methods The evaluation was process-outcome orientated, undertaken from December 2022 to June 2023, deemed the innovation’s pilot phase. A mixed methods approach was employed, incorporating a review of documents pertaining to the model, an electronic survey specific to nurses at two time points (preparation and implementation), and semi-structured interviews targeting, two groups; Group one, health system stakeholders (nurses, doctors, managers and virtual medical officers) and Group two, patients. Results The document review emphasised the important pre-implementation or exploration factors which were an interdependent platform for subsequent implementation phases, for example having a clear understanding of determinants such as the rural context, the problem and need. Interview findings (n = 77), involving Group one (n = 39); and Group two (n = 38), were categorised into three overarching themes; Facilitators of the telemedicine model, Barriers to the telemedicine model, and Sustaining telemedicine innovation gains for the future of rural healthcare. Critical preparation factors identified were the relational culture of collaboration and partnership during innovation design negotiation, and the importance of organisational and individual leadership. Implementation factors highlighted the effectiveness of the project management approach, and responsive adaptation, such as active feedback loops leading to model adjustment to increase acute ward routine efficiency. Conclusions This study has policy implications for the development of rural medical workforce strategies and the planning of a rural digital healthcare strategy. Our identification of determinants contributing to implementation success, and use of the Implementation Research Logic Model to illustrate connections, would aid decision makers when designing, introducing and adapting rural healthcare innovations to be relevant to context. rural healthcare telemedicine innovation implementation frameworks virtual inpatient clinical services medical workforce Figures Figure 1 Figure 2 Contribution to the literature This paper highlights the issue of rural medical workforce shortages in Australia. It reports on an innovative telemedicine strategy that was found to be safe, and acceptable for inpatients and nursing staff, supported local GPs, and is potentially replicable in other rural locations. It demonstrates the application of constructs from two implementation frameworks, the Exploration, Preparation Implementation, and Sustainment (EPIS) and Consolidated Framework for Implementation Research (CFIR) to identify influencing factors of preparation for and implementation of this unique telemedicine model. Synthesised findings are presented using the Implementation Research Logic Model (IRLM), illustrating critical features in rural healthcare innovation. Background Globally, general practitioner workforce availability and community health impacts are concerning issues ( 1 – 3 ). In rural contexts there is a clear juxtaposition between general practitioner (GP) roles and equitable community access to care closer to home ( 4 , 5 ). Virtual models of care have been offered as partial solutions to support GPs and rural populations across Australia ( 6 , 7 ). Guided by implementation science, this paper presents key preparation and implementation factors identified in an evaluation of a unique virtual medical officer inpatient model of care in a rural health service in northern Victoria, Australia. General practice challenges and the rural GP The GP is the pillar of rural primary care which epitomises universal access to effective, efficient and equitable healthcare ( 4 ). Primary care, as described by the World Health Organization, is the entry point to health services for the identification, treatment and management of most health problems ( 8 ). In Australia the reported challenges faced by General Practice are largely attributed to increased service demands, current and predicted workforce shortages from retirement and attrition, along with reduced numbers of practitioners attracted to the profession ( 9 , 10 ). In 2023 it was reported that there were 66.2 GPs available per 100,000 people in rural remote areas compared to 122.7 (full-time workload equivalent) in major cities ( 9 ). It has been predicted there will be a shortfall of 10,600 (full time equivalent) GPs in Australia by 2031 ( 9 ). Rural GP models and roles The prototypical Australian rural GP model of care provides both primary care in the community setting and secondary care in rural hospitals ( 11 ). This link between general practice and inpatient hospital care is accomplished by the general practitioner visiting medical officer (GP-VMO) role. The GP-VMO involves a local medical practitioner in private practice also providing medical services in a public hospital. It is a fee-for-service contract, and the practitioner must be ‘credentialed’ by a relevant body to provide in-hospital medical care. In the current context credentialing aligned with Safer Care Victoria policy ( 12 , 13 ). The GP-VMO has similar duties to a ‘hospitalist’, a salaried medical officer position that acts as the first point of contact for patients admitted to the hospital and provides overall management of inpatient care ( 14 ). Care closer to home and telemedicine solutions Care closer to home is a health system reform vision aiming for safe, high quality healthcare in the right place, at the right time for the right care need ( 5 , 15 , 16 ). The rural health service is the spatial connection for care closer to home, assisting local community members to transition through the boundaries between primary and secondary care with referral pathways to tertiary and quaternary care. Rural health services increase access for example, through hosting virtual technology to diagnostic resources and specialists, which then improves rural healthcare equity ( 5 , 6 ). The development of virtual models of care have been championed as innovations to counter geographical inequalities, provide support to local GPs, and enhance continuity of care for rurally located people ( 6 , 7 ). Innovation and Implementation frameworks To investigate innovative models of care as evidence-based, implementation science offers researchers theories and frameworks to support translation into real-world settings ( 17 – 19 ). The use of implementation frameworks is particularly important in the dynamic healthcare environment as compared to the controlled research situation. In rural hospitals, the capacity to examine implementation efforts using these concepts is minimal. In 2023 it was reported that there was a 6.5-billion-dollar deficit in health funding for Australian rural communities ( 20 ). More so, overall, there is a lack of rigorous empirical research into innovation implementation in the public hospital system in Victoria, Australia ( 21 ). Understanding the ‘how’ of implementation of initiatives such as telemedicine in rural health services, will yield insights into specific facilitators and barriers and contribute to further use of implementation frameworks in such settings. The current study is specific to telemedicine-clinical services that provide inpatient-medical practitioner interactions through virtual means in the rural acute ward setting. This paper reports on this innovative model drawing on two well established implementation frameworks; the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework, commonly used in social care settings ( 22 , 23 ) and the Consolidated Framework for Implementation Research (CFIR), used across healthcare settings ( 24 , 25 ). The Implementation Research Logic Model (IRLM) ( 26 ) was utilised to synthesise and present overall findings. The paper demonstrates how implementation frameworks can be tailored to enhance examination of implementation processes and to identify factors that influence implementation practices ( 27 , 28 ). This investigation is important as there is a lack of research into the factors which lead to effective implementation of virtual health services ( 6 ). Methods Study aims and design The aims of the study were to examine the preparation for and implementation of a virtual medical officer clinical service for the rural inpatient setting. The key questions were: 1) What successful and/or challenging features were important facilitators or barriers in the preparation and implementation of the virtual model of care; and 2) To what extent was the virtual model of care efficient and effective in contributing to access to care closer to home for rural people? A mixed methods design was employed, involving a review of processes and documents, electronic quantitative surveys and qualitative interviews. The ASSESS reporting guide ( 29 ), was applied in the preparation of this manuscript due to its suitability as a reporting tool for a mixed methods design, appropriateness for evaluation, it enabled description of both intervention and implementation efforts, along with our objective of synthesising implementation information through combing constructs from different implementation frameworks. The evaluation received ethical approval from the University of Melbourne, Ethics Committee, Office of Research Ethics and Integrity. Reference Number: 2023-25567-36201-4. Study setting The study was a collaborative undertaking between the rural health service, the Regional Health Service Partnership ( 30 ), and the local University Department of Rural Health. It involved three campuses of a rural health service in northern Victoria, Australia. The health service provides care to a local population of approximately 30,500 persons covering an area of 4,045 square kilometres ( 31 ). The individual populations of the three townships where the health service has a campus located (largest to smallest; figures rounded) are: 6,000; 4,480; and 2,000. At each campus the following number of acute ward beds are available; campus one,16 beds; campus two, 12 beds; and campus three, 6 beds. The innovation: a virtual medical officer model of care The innovation was actively piloted at the rural health service from December 2022 to June 2023, it then became embedded as an ongoing service model. The virtual service was introduced to assist with weekend, after-hours medical coverage of inpatients in the three acute wards of the rural health service. It was a unique use of telemedicine developed to be complementary to the usual model involving GP-VMO arrangements. The duties of the virtual medical officer included direct patient consultations, reviewing medications, ordering medical tests (for example X-rays, blood tests), patient admissions into the rural acute wards, updating patient notes and medication orders, discharging patients, issuing prescriptions and providing handover to the patient’s usual medical care provider. The virtual doctor visited inpatients at their bedside through an electronic tablet, as illustrated in Image 1. All interactions were facilitated by a nurse as would occur with a traditional GP-VMO consultation. A leading Australian virtual care business supplied the service, which was founded on the combined experience of medical doctors and technology professionals to provide clinical and software solutions to the healthcare sector ( 32 ). Place Image 1. about here Participants The study targeted two groups of participants: 1) health system stakeholders and 2) health consumers. Group one included the rural health service’s management and nursing staff, regional health system representatives, local GP-VMOs, and the virtual health care provider’s medical practitioners. Group two were patients who had experienced the telemedicine service. An information flyer was available to promote the evaluation, supported by a plain language statement. Individual consent for participation was required. Data collection The processes and documents sourced for the evaluation included project management documents (for example, project plans, minutes of project governance group meetings); health service operational documents such as policies and procedures to guide telemedicine use; resources developed by the health service and telemedicine provider; patient information such as community newsletter articles, health service Facebook posts. In addition, the telemedicine service data for the pilot period was tracked for each campus. Researcher designed surveys for health service nursing staff were managed using REDCap, a secure web application for data capture ( 33 ). Surveys were distributed at two time-points T1: model preparation and T2: model implementation. Surveys were open for two weeks with a reminder sent out at the beginning of week two. The T1 survey included statements about virtual medical officer service awareness, communication, and training. At T2 statements about experiences of the service were added. A 6-point rating scale (1 Very poor to 6 Excellent) was used. At both survey time-points optional free-text comments were invited using open-ended questions about successes and challenges of the model (see Additional file 1 for the complete survey). Individual interviews for all participants were undertaken over May to June 2023. They took place either face-to-face or through videoconferencing (Zoom or Microsoft Teams) using only the audio recording function. Semi-structured interview questions were developed by researchers. Group one (health system stakeholders), interviews included questions about overall experiences of the telemedicine model, and successful or challenging aspects about the preparation for and implementation of the pilot innovation. Group two (patient) questions asked about feelings of safety, care experienced, and use of virtual inpatient care again (see Additional file 2 for all interview questions). Data analysis A content analysis of processes and documents were undertaken through a deductive approach using constructs from the EPIS ( 34 ) and the CFIR ( 24 ) implementation frameworks as guiding categories ( 35 , 36 ). A table developed in Microsoft Word was utilised to record this information. Survey data were retrieved from REDCap via a Microsoft Excel spreadsheet. These data were analysed descriptively, and results tabulated for presentation, along with a summary of respondent’s free-text comments. All interview recordings were transcribed by the first author. Participants were assigned a unique identifier to protect anonymity; for example, health system stakeholders were assigned an ID of #HSS01; a patient #P01. Transcripts were analysed by two authors using the Qualitative Framework Approach ( 37 , 38 ). This is a stepped method which involves researcher familiarisation with transcripts through reading and re-reading and applying initial codes to passages ( 39 ). Then, through an iterative process, researcher agreed codes were organised into categories for refinement and then interpretation of themes. To guide triangulation, constructs from the EPIS and the CFIR implementation frameworks were utilised. The IRLM was employed for syntheses and to provide a visual representation of implementation efforts and associated change mechanisms; it also assisted with combining implementation framework components ( 40 , 41 ). An adapted conceptual depiction of the IRLM ( 26 ) is shown in Fig. 1, noting key elements from the EPIS and CFIR, implementation frameworks. Place Fig. 1. about here Results The results commence with a summary of the telemedicine service data tracked for the pilot period and provided in Table 1. It is notable that during the pilot no clinical incidents were recorded and no patients required escalation of care to a large regional centre. The process and document review are presented next, these are followed by survey results and then findings from the analyses of interview transcripts. Table 1. Telemedicine inpatient service data December 2022 to June 2023 Place Table 1. about here Process and document review Presented in Table 2 are the results from the process and document review which have been classified using the four phases of the EPIS (column 1), followed by the strategies identified from the analysis (column 2), and then aligned to the implementation constructs of the EPIS and the CFIR (column 3), finally a description of the associated evidence and actions are provided (column 4). Table 2. Summary of process and document review results aligned to implementation constructs Place Table 2. about here Health service nursing staff survey At the preparation phase (T1), n = 15 nursing staff responded to the survey, and at implementation phase (T2) six nurses took part. The lower number of responses at implementation reflects completion of the survey by nurses who had direct experience of the telemedicine model and were on duty when the service was active. In summary, nursing staff showed high awareness (93%) of the model introduction at preparation and very good-to excellent ratings for quality of care (100%) at implementation. Survey questions and results are provided in Additional file 1. Leadership at the rural health service believed that a specific examination of rural nurse impact when implementing virtual inpatient care was warranted and these results have been reported elsewhere ( 42 ). Interview findings Overall, 77 participants were involved in interviews; Group one (n = 39); Group two (n = 38). Characteristics of each group are described in Table 3; thematic findings are then provided. Table 3. Interview participant characteristics, Group one (HSS) and Group two (P) Place Table 3. about here Interview themes Findings are presented under three themes and subthemes with example quotes. As occurred with the document review (see Table 2) alignment with the phases of the EPIS Framework have been identified, and constructs from both the EPIS and CFIR are included. Theme 1. Facilitators of the telemedicine model All participant views indicated overall high satisfaction with introducing the virtual model of care for the acute ward. The successful aspects of the pilot are grouped into four subthemes with supporting quotes. Subtheme 1.1 Understanding the context, problem and solution This subtheme aligns to the EPIS Exploration stage, and the construct of Innovation Relative Advantage (CFIR). Stakeholders articulated the need for healthcare service delivery improvement. They had a thorough understanding of the need, potential solution and the case for change, as exampled by a participant quote, The project has been a way to provide medical cover in the ward. This has come at a time when we are really facing care not being delivered due to the decreasing GP workforce in rural health services . (#HSS04) Subtheme 1.2 Scope, negotiation and support to execute change This subtheme shows the connections between the EPIS Exploration and Preparation phases. It highlights the features that firstly, assisted to prepare for change and then, aided in the implementation. These included resource support of personnel, funding, and project planning and management aspects, as acknowledged by the following, Setting the project up to succeed about what was its scope, what were we trying to achieve, how we're trying to achieve it. (#HSS11) I think having project resources, with the project lead, has been instrumental in its successes as you have got someone to coordinate the effort. (#HSS01) In addition, it provides an example of partnerships and connections (CFIR). The negotiations which assist with planning to introduce change were vital, as one stakeholder stated, We were able to pre-emptively solve a lot of problems before they came up. The feedback allowed us to design the technology and the service so that we had already anticipated many of the streams and the content of the communication that was required to be able to run the service . (#HSS05) Subtheme 1.3 Successful interactions through engagement, relationships, and communication This subtheme demonstrates the Relational Connections across the Inner Context/Setting and Outer Context/Setting (EPIS and CFIR). The importance of connecting at different levels and by various means was stressed by interviewees. The professional interactions highlighted the importance of building engagement from the beginning, I think stakeholder engagement is a very key and integral part of rolling out a new model of care like this . (#HSS06) The care interactions emphasised sensitivity and responsive communication by the virtual care provider and highlighted respect for staff and patients. Two examples are given, A very positive aspect is the [provider name] doctor is happy to engage with [nursing] staff and happy to listen and act upon our concerns. (#HSS12) The patients appeared to feel that somebody had more than a couple of minutes to spend with them. It helps that [doctor name] has got a really good bedside manner. He has patience and he listens, and he's interested. That was nice. (HSS#07) Patient’s experiences highlighted how communication facilitated the doctor-patient relationship and there were observations about positive relationship building with nurses, as these following excerpts exemplify, Doctor [name] was very professional but down to earth (#P09); Doctor [name] really listened to me and my needs, he really cared and helped me. (#P13) and, Doctor [name] was great to deal with, he seemed to get on with the nurses . (#P29) Subtheme 1.4 Impact on care, people, and place This subtheme captures the EPIS Implementation Stage and areas of acceptability, satisfaction efficiency, and effectiveness (EPIS and CFIR). There were positive impacts on care, people and place. Patients overwhelmingly confirmed feelings of safety, care was as it should be, and they would use the virtual service again. Descriptions were provided about the positive impact of access to care and highlights the importance of the provision of care over the weekend or out of hours within the rural acute ward. Patients commented that they appreciated the health service making this service available, it was also indicated that carer stress was reduced due to this service access, for example, I felt relieved that a doctor would be reviewing him [husband] over the weekend. (#P05) Care efficiencies were accentuated by processes, such as access to electronic medication charts. As stated by an interviewee, An electronic medication chart, limits the risk of transcribing issues etcetera and makes it really clear and accurate for staff to use. (#HSS10) Effectiveness of access to care closer to home was highlighted by perceptions about the impact for patients, for example, Everyone likes to come back to their local health service, to their own hometown. We normally wouldn’t have that capacity to take patients back over the weekend; with [name of telemedicine service] we now have that flexibility. (#HSS02) The impact on GPs considered the current and ongoing situation, as this next excerpt highlighted, Good for GPs to have a break, especially as we have less GPs doing on call. We don’t want to lose anymore GP’s. (#HSS12) Theme 2. Barriers to the telemedicine model The barriers identified by stakeholders were not seen as negatives or an indication that the telemedicine model was flawed but rather, there were things that arose which needed to be addressed. There were three subthemes which emerged that relate to Bridging and Innovation factors to assist with barriers and challenges (EPIS). Subtheme 2.1 Challenges in adjusting the traditional inpatient model of care The consideration of the effects on health service staff, particularly nurses and local GP-VMOs, and the traditional inpatient model of care in the acute ward was important. The changes required adjustments to their workload, the first example is about GPs and the second relates to nurses, Sometimes we are busy and can’t communicate or give a handover to the telemedicine doctor. (#HSS29) It was time consuming. By adding in doctors’ rounds on weekends, this was an increased workload. Spending over an hour doing a doctor's round that we had never done before. (#HSS07) Subtheme 2.2 Challenges in managing perceptions An area that was repeated in several of the interviews was the nature of the virtual model of care and cautioning that it is not a replacement service, nor should it inadvertently be a means to ignore disadvantage or access and equity issues. Highlighted was the importance of negotiations during the EPIS Exploration stage, as phrased by interviewees, In our discussions with our GPs and VMOs about [name of telemedicine service] and the service offered, being very mindful that we are not trying to take business away from them, we are just trying to add a complementary service in to work alongside our existing GPs . (#HSS10) It’s about supporting the local GPs, not substituting their care. And not substituting them on the rosters. (#HSS31) Subtheme 2.3 Challenges posed by complacency This subtheme drew on interview content that alluded to the healthcare setting not becoming complacent in seeking feedback and engaging in continuous quality improvement. It was seen as essential that regular and ongoing updates about all aspects of the model is actively sought, and that patients remain a priority, It’s important we are learning from all feedback; what are we learning from the model; what are we learning from the good experiences and the not so good experiences. Also, are we undertaking any follow-up studies for example, monitoring of patient’s care and their engagement with the health care system. (#HSS21) Theme 3. Sustaining telemedicine innovation gains for the future of rural healthcare Participants were cognisant that the pilot was successful but aware there are broader ongoing challenges facing rural and regional areas. It is relevant to the EPIS Sustainment stage. The findings from this overarching theme were grouped into three subthemes with exemplifying quotes. Subtheme 3.1 Caring for the rural population and the rural workforce This subtheme is indicative of Innovation Outcomes (CFIR) and connects to quality of life for the rural population and workforce. It shows that caring for those living and working rurally is interdependent, as shown by the next two quotes, It’s reassuring that patients are being looked after over the weekend. (#HSS28) As long as patients are happy, I am happy. (#HSS27) Patients indicated they valued the continuity of care offered by their local GP and were concerned about the loss of the local healthcare workforce. It was emphasised by patients that they preferred their own local doctor, and some felt the virtual service was not as personal as having an in-person doctor consultation. However, it was also acknowledged that to retain the local GP workforce they need support, and this type of service would provide them with a break. Subtheme 3.2 Sustainability and replicating the telemedicine model This subtheme exemplifies the Sustainment stage (EPIS) whereby consideration of long-term determinants is key. There was an understanding that rural healthcare needs are continuous and likely to increase, and a skilled and viable workforce is essential. The following excerpt highlights these opinions, That agility will become more important with not only the medical workforce but the clinical workforce as we become more and more challenged in rural areas. We need sustainability with care for an ageing population, more chronic disease and so forth. We need to look at different ways of doing things. (#HSS04) Stakeholders felt a responsibility to continue to embed and improve the telemedicine model and to ensure that the experiences of this rural health service initiative are more widely available, as this next quote exemplifies, Part of the role of the partnership is scale, sharing expertise, the project coordination. It's about where the scale, the processes and coordination and the shared expertise goes with this pilot. (#HSS11) Subtheme 3.3 The need for a rural digital health strategy This subtheme reflects the influence of the Outer Context/Setting (EPIS and CFIR) the determinants of which can be mediators or moderators of innovation. The policy environment was evident as an area in which to advocate for innovative models of care for the rural healthcare context, such as this inpatient virtual medical officer service, as explained by an interviewee, The persistent shortage of staffing in the regional areas and working in this industry for the past years and dealing with different specialties, we believe that we wouldn't have a quick cure. So, we have to embrace a complementary model as part of the public health strategy in the future. A digital health strategy and partnerships to better utilize specialists’ capacity. (#HSS26) Triangulation and synthesis of all results To bring together the mixed methods study results, triangulation was undertaken and then synthesised as a visual representation. Triangulated results are provided descriptively in Table 4 under the four domains of the IRLM (see Fig. 1). As previously stated, this was guided by two implementation frameworks (EPIS and CFIR). The synthesised findings are depicted in Fig. 2. Table 4. Results of triangulation Place Table 4. about here Place Fig. 2. about here Discussion This study investigated preparation and implementation factors for a virtual medical officer model of care for clinical services in three acute wards at a rural health service in northern Victoria, Australia. We aligned the results to constructs from two implementation science frameworks, the EPIS and CFIR, to highlight key factors of innovation implementation. The synthesised findings were presented using the IRLM. Our discussion reflects on the important features identified from this analytical process that promote successful implementation and may encourage the further use of implementation frameworks. Preparation factors The reporting of preparation factors when introducing healthcare innovations is limited. As revealed by a systematic review by Moullin, Dickson ( 34 ) of 49 included implementation research studies, 14 were explicit about exploration and 18 about preparation. Similarly, Powell, Patel ( 43 ) stressed the critical nature of attending to these early stages to ensure innovation feasibility and implementation success. Our study has emphasised the significance of exploring and preparing for innovation implementation. It has identified that factors such as detailed attention given to understand the contextually specific antecedents which influence the problem and consideration of the evidence to develop a solution, ensure a viable platform to introduce the innovation. In addition, early use of a systematic strategic approach was enabling throughout implementation (as described in Table 2 and illustrated in Fig. 2). The synthesised findings showed that exploration was extensive but seamlessly joined with preparation and the design of the innovation. This accentuated the relational culture of design negotiation between stakeholders. Research has identified that health interventions can fail due to poor design and/or implementation ( 44 ). The design of the virtual medical officer model of care was achieved through the relational mechanisms of leadership, collaboration and partnership. These were individual characteristics but also organisational characteristics amongst the negotiating stakeholders, i.e. the rural health service, the telemedicine provider and the Regional Health Service Partnership. In addition, this factor was seen to positively influence translation and dissemination in the sustainment stage. Implementation factors A feature which supported transition from preparation to implementation was the project management strategy that was supported by resourcing with funding and knowledge and skills. As detailed in Fig. 2, this strategy embedded delivery systems, supported the team and individuals and enabled change management. As described by implementation science researchers an implementation strategy defined through actor and action mechanisms can overcome barriers and activate facilitators ( 45 , 46 ). Our study provides pragmatic descriptions of the link between the project management strategy, mechanisms, outcomes and functions of bridging and innovation factors, and captures these in our virtual medical officer model of care IRLM descriptors (see Fig. 2). In addition, the implementation factor of project management was a critical mechanism in the capacity for adjustment of the model. This involved incorporating active feedback loops. This mechanism, whereby nurse and patient experiences were acted upon and adjustments made to the model of care in ‘real time’ (described in Table 2), highlighted the adaptable elements. The identification of this factor shows how the specific nuances of context informed the modification to the model of care but did not alter the core elements of the innovation design developed from evidence ( 44 ). Further, this is significant as it can inform planning for intervention insertion into other contexts for replication or scalability ( 47 ). Combining implementation frameworks We sought to present novel insights from the evaluation data by using constructs from the EPIS and CFIR and then synthesising the information graphically through the IRLM, as an organising framework ( 40 ). The rationale was to examine the multileveled and multidimensional nature of rural innovation and identify the distinct features which may contribute to implementation success. The possibilities in combing implementation frameworks are recognised in the literature as assisting with gaps and increasing the breadth and depth of analysis ( 48 ). However, researchers also suggest that using multiple frameworks can result in unnecessary complexity ( 48 , 49 ). Our use of the frameworks has highlighted the importance of understanding the different phases of implementation (EPIS), particularly how exploration and preparation are essential platforms to transition to subsequent stages for successful implementation. In addition, the EPIS was beneficial when considering bridging and innovation factors and how these assisted with navigating the boundaries between contexts or settings. The CFIR was helpful in identifying the determinants of implementation in healthcare; and this is the most commonly cited reason for using a framework ( 50 ). Used in our analyses it emphasised the importance of defining constructs within domains to ensure the framework is relevant to the site of implementation. As recommended by Damschroder, Reardon ( 24 ), subjects of domains should be defined and specific language, appropriate for the implementation situation, used to describe constructs. Both frameworks were valuable to identify nuances about context (EPIS) or settings (CFIR); these terms are complimentary and perhaps interchangeable, as found by the review by Watson, Adams ( 51 ). We suggest, that for rural healthcare research about innovation implementation they should be uniquely described. Particularly, as in the current study, the rural synergies between primary care and tertiary care are very different to urban models of care. Descriptions of ‘outer context’ for rural healthcare researchers emphasise the spatial connections of people and place along with geographical features of location regarding access, equity and the social determinants of health ( 52 , 53 ). ‘Inner context’ is helpful to describe for example, workforce culture, where rurally this is often influenced by historical and generational relationships with patients and their families which can influence knowledge, attitude and behaviour when introducing practice change ( 19 ). In contrast, in defining ‘outer settings’ this may showcase for example, the policy and legal climate, the complexities of national and state funded healthcare systems, and healthcare workforce strategies ( 51 , 54 ). ‘Inner setting’ can describe resource availability, educational requirements and as evidenced by Fernandez, Walker ( 55 ), are important to recognise implementation influences at the clinical level. Nuanced lenses about context and settings would increase insights into the multidimensional (macro to micro) features of implementation and the identification of facilitators and barriers as we have indicated in Fig. 2. Presenting our synthesised findings by using the IRLM was effective in distilling the evaluation information ( 40 ). This logic modelling approach (see Fig. 2) showed the connections between strategies and mechanisms and emphasised causal pathways, which together support the translation of evidence to practice ( 26 , 41 ). Its utility in succinctly presenting information would encourage further use of implementation frameworks by any healthcare discipline. Policy implications This study has policy implications for the development of rural medical workforce strategies and the planning of a rural digital healthcare strategy. The virtual medical officer model of care for the rural acute ward was designed to provide professional support to local GPs, relieve role burden and to be complementary to existing arrangements. A principle noted in the Victorian Department of Health’s virtual care strategy, although not specific to rural General Practice, is the use of virtual care to be a complementary tool ( 7 ). As we have identified, it is critical that virtual models are not used as replacement services or inadvertently become a means to ignore disadvantage or access issues. Further, it is essential that rural patients’ needs and preferences are acknowledged and appropriately met, and service delivery innovations remain sensitive to patients at the centre of care. Ongoing considerations concern continued vigilance about healthcare equity for rural communities. Study limitations This study has several limitations which must be acknowledged. The evaluation was time-limited to the pilot of the virtual medical officer model of care, a gap is the lack of a monitoring phase to measure ongoing impact and collect evidence about changes in the model over time. The innovation was introduced at an individual rural health service in a single geographic area of Australia, serving patients who are elderly (over 65 years). Hence, there was relatively limited diverse representation in terms of rurality, age and cultural diversity, limiting the evaluation outcomes generalisability. However, some of the characteristics described are common in rural settings and this supports the model as being replicable in other locations, particularly for rural inpatient services experiencing GP-VMO workforce shortages. In addition, authors acknowledge that further research is essential to investigate the economic factors associated with this model of care and the impact on workforce outcomes for rural GPs. Conclusions Overall, participants (nurses, GPs, health system representatives, the virtual provider and patients), were positive about the introduction of the virtual model of care. The evaluation found the model to be acceptable, satisfaction was high and helpful outcomes were achieved, as identified by IRLM outcome categories. The IRLM provided an example of the versatility of this diagrammatic representation, its practicability in combining elements from two implementation frameworks, and assisted with highlighting the application of the innovation to practice. The importance of pre-preparation, preparation and implementation factors highlighted from our study will aid decision makers when negotiating, designing and introducing rural healthcare innovations. Abbreviations CFIR Consolidated Framework Implementation Research EPIS Exploration Preparation, Implementation, Sustainment GP General Practitioner IRLM Implementation Research Logic Model VMO Visiting Medical Officer Declarations Ethics approval and consent to participate The evaluation received approval from the University of Melbourne, Ethics Committee, Office of Research Ethics and Integrity. Reference Number: 2023-25567-36201-4. Participation in the study was voluntary, and no incentives were offered to any participant group. Consent was obtained from each participant prior to all data collection activities. Consent for publication Consent was received for the individual’s image (Image 1) included in this manuscript. Availability of data and materials Nursing staff survey questions and all results are available in Additional file 1. Interview questions for both participant groups are available in Additional file 2. All other materials are available on specific request to the corresponding author. Competing interests Authors, CS and RW, are part of the Telecare Australia Pty., Ltd, group who were the providers of the telemedicine service but were not involved in any data collection, data analysis, synthesis, or conclusion development. Funding No funding was provided for the research reported and in the preparation of this manuscript. Authorships’ contribution CR: study protocol development, ethics application, data collection, analysis and interpretation of findings, first draft of manuscript, subsequent refinement and editing of paper. CC: study protocol development, data collection, analysis and interpretation of findings, reviewing and editing of paper. VJ: data collection and analysis, reviewing and editing of paper. KCT : topic area expertise, reviewing, and editing of paper. AF: reviewing and editing of paper. CS: topic area expertise, reviewing, and editing of paper. RW: topic area expertise, reviewing, and editing of paper. JP: reviewing and editing of paper. MA: Implementation framework expertise, reviewing, and editing of paper. All authors read and approved the final manuscript. Acknowledgements This study was undertaken on the unceded lands of the Yorta Yorta Peoples. The authors acknowledge the Traditional owners of the land and pay our respects to all Elders past and present. The project acknowledges the Australian Government Department of Health and Aged Care Rural Health Multidisciplinary Training programme. Additional information Additional File 1. Nursing staff electronic survey Additional File 2. Semi structured interview questions References Karuna C, Palmer V, Scott A, Gunn J. Prevalence of burnout among GPs: a systematic review and meta-analysis. Br J Gen Pract. 2022;72(718):e316–24. https://doi.org/10.3399/BJGP.2021.0441 . Shen X, Xu H, Feng J, Ye J, Lu Z, Gan Y. 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Telemedicine inpatient service data December 2022 to June 2023 Campus In patients Ward rounds Patient consultations New admissions Weekends serviced Transfers to acute hospital Campus one 78 17 163 2 9 0 Campus two 63 15 111 3 8 0 Campus three 33 17 56 0 9 0 TOTALS 174 49 383 5 26 0 Table 2. Summary of process and document review results aligned to implementation constructs Column 1 Column 2 Column 3 Column 4 Implementation stage (EPIS) and timeframe Strategies Implementation constructs (EPIS and CFIR) Description of associated evidence and actions EXPLORATION PHASE 2021 Health service strategic plan, identified care Close to Home as a priority pillar October 2022 negotiation about a virtual VMO model of care was underway Problem identification Antecedents (CFIR) Concerns were raised about local GP workforce burnout. Tracking from 2017 to 2023 of local GP numbers revealed a 75 percent reduction in on-call availability to attend to patients in the rural acute wards. Local rural health service situation: acute beds available, with limited admissions capacity and capability. Unable to accept acute ward admissions due to lack of VMO availability. Tertiary regional health service situation: high demand and internal bed pressures, impact on workforce and other resources, impacting patient flow. Too many admissions for health service capacity. Solution identification Antecedents (CFIR) Virtual services were flagged among potential solutions. There was an opportunity to develop a virtual model of care, which offered additional (off-site) Medical Officer capacity. Systematic, strategic approach Implementation methods (EPIS & CFIR) A systematic, strategic approach was enabled through the Regional Health Service Partnership (Victorian Government, 2021). This entity works in collaboration with members to advance strategic system priorities determined by government and local priorities agreed upon by members. Intervention identification Evidence-based innovations (EPIS & CFIR) The success of virtual services for local urgent care needs such as, My Emergency Doctor (My Emergency Doctor, 2024) and the Victorian Virtual Emergency Department (VVED) (Northern Health, 2022), highlighted models which relieved rural GP-VMO on-site attendance. Negotiation with intervention providers Bridging factors between the inner and outer contexts (EPIS) Originally, the telemedicine provider was exploring business opportunities. Their initial models were based on outpatients in rural areas using telemedicine to assess a whole range of medical specialists for non-urgent consultations. That was not the need, and the volume for that type of clinical activity wasn’t viable in the rural location. Intervention design Innovation factors characteristics of the intervention & the developers (EPIS) A series of discussions with the telemedicine provider began. This was to explore their interest in using their telemedicine platform to support other clinical activity, which is more voluminous and regular, and in greater need of support at the rural health service. The virtual Medical Officer model of care for clinical services in the rural acute ward began to emerge; it was to be complementary to the existing local GP-VMO “traditional” care arrangements. Intervention system alignment Outer context & bridging factors (EPIS) Outer setting (CFIR) An extended process occurred to convince the public health system structure to consider alternative models of care such as this, including directors of medical and clinical services. The complexities of virtual health care, and the interface between private provider models and the public healthcare system were highlighted in the review of all documents for the evaluation. PREPARATION PHASE October 2022 to December 2022 Establishing partnerships The boundary between the Inner Setting and Outer Setting (CFIR) The proposal for this model of care was presented to the Regional Health Service Partnership, a CEO Council of 15 health services across the region (Victorian Government, 2021). The briefing paper to CEOs informed all stakeholders, assisted with engagement and partnership connections, secured project management funding and established roles and responsibilities for the pilot. Project management Individuals domain (CFIR) Project management was initiated in order to facilitate a change management process. A project lead was appointed, project governance established (e.g. reporting lines, communication, Terms of Reference) and members appointed for a project working group. Legal contract Outer Setting domain (CFIR) Contract negotiations commenced between the telemedicine provider and the health service and its legal representative. It was envisaged that the contract template could be replicated if additional rural health services wished to implement this telemedicine model. Documentation development Inner setting domain (CFIR) A suite of model of care, management and operational documents were developed. An example operational document was the Health service procedure on telemedicine use to provide guidance and advice to nursing staff about the use of the virtual doctor service. This procedure included admission criteria and exclusion criteria. Communication resources Inner setting domain (CFIR) Patient and staff information material was developed, distributed, and reviewed. Intervention knowledge Inner setting domain (CFIR) Staff education and training were developed, offered and conducted at all health service campuses. Intervention provider credentialing Outer context (EPIS) Outer Setting domain (CFIR) The telemedicine, medical practitioners undertook credentialing in accordance with the Safer Care Victoria Medical Credentialing and Scope of Clinical Practice Policy (Safer Care Victoria, 2023). This is a compliance requirement to provide independent medical services to hospitals in Victoria. Comparable credentialling is required in all states and territories of Australia. IMPLEMENTATION PHASE December 2022, service goes live; February 2023 model operational at all three health service campuses Adaptations and problems solving Inner setting domain, innovation factors (CFIR) During implementation iterative review and adjustments were made to enable re-orientation in-situ. Throughout the pilot feedback was tracked to identify issues and then problem solving occurred to arrive at viable solutions. Examples are reviewing the patient criteria for virtual doctor use and adjustments to the nursing routine in the wards. Quality of care processes Inner setting domain (CFIR) Health service processes for clinical review were imbedded during the pilot to ensure the safety and well-being of all patients receiving the intervention and health care staff involved with delivery. The process for clinical review followed current procedures where anything that would normally meet a trigger for clinical reviews would be included, e.g., unplanned transfers out, adverse events such as falls, Hospital Acquired Complications (HAC). SUSTAINMENT PHASE 2024 - ongoing Post intervention pilot scalability Bridging factors between the inner and outer contexts (EPIS) Post-pilot, the continuation of the model has been successful. The evaluation provided evidence which supported its efficiency, effectiveness and safety. In addition, scalability options and adaptation and further development were considered with the creation of generic document packs, ready for specific health service branding to enable use by other health services Abbreviations: CFIR – Consolidated Framework for Implementation; EPIS-Exploration, Preparation, Implementation framework; GP-General Practitioner; VMO-Visiting Medical Officer Table 3. Interview participant characteristics, Group one (HSS) and Group two (P) Group Interviews Description Group one, health system stakeholder (HSS) characteristics There were 51 stakeholders invited to take part, 39 accepted. Interviews ranged from 30 to 60 minutes. HSS participants were n = 25 (64%) females, and n = 14 (36%) males. Interview participant subgroups were, health service staff including management and nurses (n = 24); regional health system representatives (n = 9), GPs-VMOs (n = 3), and the virtual health care provider’s physicians (n = 3). Group two, patient (P) characteristics Interviews ranged from 10 to 20 minutes and were undertaken whilst patients were still on the ward. Patient interviews involved females n = 21 (55%) and males n = 17 (45%). The age range was 64 to 91 years, with 36 participants (94%) over 65 years, grouped into age categories this equated to 65 to 74 years, n = 8 (21%); 75 to 85 years, n = 10 (26%); and 85 years plus, n = 18 (47%). Table 4. Results of triangulation IRLM Domain 1. Determinants – aspects which may be barriers or facilitators Intervention characteristics: the ‘thing’ (a telemedicine model of care for the rural acute ward setting) being implemented. Barriers: the innovation design required extensive negotiation at the exploration stage to develop a contextually relevant model that was safe, provided high-quality care and was patient centred; the model is reliant upon technology, and this could be a moderator to its efficiency and effectiveness due to inherent issues often exacerbated by the rural location, such as internet interruptions, slow connections and delayed/blocked email communications. Facilitators: published evidence about the success of other telehealth models; precedents with other telemedicine models in use; robust track record of the telemedicine provider; the enhanced adaptability of the model as negotiated between all stakeholders; the appropriateness of the innovation pilot given the evidence about need and the case for change (i.e. to a virtual VMO model of care). Inner setting: the rural context of the innovation, including the health service and community served along with the teams involved with the pilot. Barriers: various understandings about the model and the complex work involved in educating all systems and stakeholders; translation of the model into practice. Facilitators: access to project management resourcing and the appointment of a project lead to effectively mediate the barriers to achieve translation to practice. Outer setting: the broader context which influenced the implementation of the innovation (model of care), such as the socio-political environment inclusive of legislation, government healthcare policy. Barriers: dissonance between the public health system and private health sector models. Facilitators: the critical linkages between the inner and outer setting boundaries were provided by the Regional Health Service Partnership (i.e. CEO council of 15 regional health services); the collaborative approaches to comply with public health system requirements, for example credentialing of telemedicine medical practitioners. Individual characteristics: the inner and outer setting roles and responsibilities of all stakeholders. Barriers: various predicted and unknown moderators to stakeholder acceptance of the innovation (virtual VMO model of care), for example attitude to changes to the traditional model of care. Facilitators : multi-level leadership (e.g. executive decision makers, subject matter experts, project lead’s translation to practice skills), was evident at all stages of implementation; in addition, a relational culture of partnership and collaboration and transparent negotiation between all stakeholders. Processes: the support activities to apply the innovation Barriers : resource availability; effectiveness of communication activities (e.g. acute ward nurse uptake of education; reach of community/patient information). Facilitators: development of community messaging; health service policy regarding telemedicine usage; embedding of evaluation into the pilot. IRLM Domain 2. Implementation strategies – the methods used to transfer evidence into practice Preparation factors: the methods associated with exploration and preparation for the innovation. Assessment of the climate and readiness for change: this strategy encompassed knowledge of place and history. Clear understanding of the rural context, the problem and need. Willingness to brainstorm and advocate for an appropriate and acceptable solution. Engaging a range of stakeholders in planning of the innovation. A multidisciplinary approach taken to develop the model of care. Implementation factors: the methods associated with activating the innovation into practice. Undertaking a project management approach to implement the innovation: this strategy connected processes and people (e.g., local GPs, virtual medical practitioners, nursing staff, patients), and enhanced pilot feasibility and compatibility of the new model of care for insertion into the inner (rural acute ward) setting. IRLM Domain 3. Mechanisms – the detailed components of implementation strategies which steps out the actions to link to cause and affect Bridging factors: assist to navigate the boundaries between the inner and outer contexts. Relational approaches were key bridging factors, including innovative leadership, trusted leaders, ongoing negotiation, transparent collaboration and strong partnerships. Innovation factors: assist with flexibility or adaptability of the innovation to maximise its contextual fit. Adaptations to the model during the implementation stage contributed to its success as problems were identified and solved in real-time, for example, streamlining process for acute ward nurses to reduce time burden IRLM Domain 4. Outcomes - evidence which captured the successes of the innovation pilot and potential effect modifiers to the model are noted. Outcomes are described under subheadings as follows: Implementation outcomes: the virtual VMO model was found to be appropriate to address the identified need and to provide an efficient and effective solution; the model is replicable and scalable to other rural contexts. System outcomes: a tested virtual inpatient model of care to provide rural health services with medical practitioner coverage on weekends and to provide relief to the GP-VMO workforce. A replicable package is available for other rural health services to implement the model, noting the lessons from the evaluation of the pilot. Potential effect modifiers: rural GP workforce shortages, attraction and retention remaining critical issues, the model being complementary and not a replacement for the rural GP workforce. Service outcomes: a viable virtual VMO model which contributes to the rural health service’s strategic plan and goals, for example to provide local, personalised and accessible care close to home. The model continues at the health service. Staff outcomes: reported acceptance of the virtual model; evidence of increased professional learning for acute ward nurses when interreacting with the telemedicine provider’s medical practitioners; satisfaction amongst staff with the quality of care provided. Patient outcomes: patient reported acceptance and satisfaction with the telemedicine model. Potential effect modifiers: patients value their local GP and were concerned about loss of their local GPs. Clinical outcomes: patient reported improvement to their clinical situation, for example medication change which resulted in improvement to a leg wound; nurse reported improved clinical outcomes due to timeliness of access to care (weekend/afterhours coverage). Image Image 1 is available in the Supplementary Files section. Supplementary Files AdditionalFile1..docx AdditionalFile2..docx Image1..png Image 1. Commencing a virtual ward round ASSESSReportingTool.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 11 Jun, 2025 Reviewers agreed at journal 01 Apr, 2025 Reviewers invited by journal 01 Apr, 2025 Editor assigned by journal 12 Mar, 2025 First submitted to journal 11 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Reid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIie3RvQrCMBDA8QsFHdTOET/6CoqDFcRnyVHwKQQrhfoMgg9RKfixVQp1iboGXOzuoLgILqa6OMWODvkP4Zbf3RAAne4vIy4F6AMYck5d+UT5yPBDMB8BkCT+TLlId+pNBIyOuCqW8IxraJqCkXtZQep869mQnHDjVcIWcuhUBTNqKkIp+pS4JwziylLOgIFgoCZWmpFDRlYPScaSGE/1FZKR6H0FJGEtwQrqK2X0bJY4HUlCipy2Zzz1e3MVKe5ScR0NGsFxv7je1n3L3DmxuCjIO/a1ArLP/QV0Op1O96MXEAFPwXGRBxIAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-0332-8047","institution":"University of Melbourne","correspondingAuthor":true,"prefix":"","firstName":"Carol","middleName":"Joy","lastName":"Reid","suffix":""},{"id":436948891,"identity":"17f03d8b-77fc-4bd9-93c6-6aea3d980daa","order_by":1,"name":"Catherine Church","email":"","orcid":"","institution":"NCN Health","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Church","suffix":""},{"id":436948892,"identity":"e4b611c3-2636-43fa-b45e-41649a3a5e7d","order_by":2,"name":"Viv Jeffery","email":"","orcid":"","institution":"Goulburn Valley Health","correspondingAuthor":false,"prefix":"","firstName":"Viv","middleName":"","lastName":"Jeffery","suffix":""},{"id":436948893,"identity":"78b627e8-d8f8-4b2d-ab0b-7aec50fb0429","order_by":3,"name":"Ka Chun Tse","email":"","orcid":"","institution":"NCN Health","correspondingAuthor":false,"prefix":"","firstName":"Ka","middleName":"Chun","lastName":"Tse","suffix":""},{"id":436948894,"identity":"ba133e04-7459-4d81-9bf4-aff1567ad6fd","order_by":4,"name":"Andrew Freeman","email":"","orcid":"","institution":"Goulburn Valley Health","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Freeman","suffix":""},{"id":436948895,"identity":"eb5fbe3d-d7f0-43c3-bbec-ad9cc1648cc5","order_by":5,"name":"Christopher Sia","email":"","orcid":"","institution":"Alfred Health","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Sia","suffix":""},{"id":436948896,"identity":"893f4e47-352e-4a8e-a80b-0fd93ed75c81","order_by":6,"name":"Raymond Wen","email":"","orcid":"","institution":"North Western Melbourne Primary Health Network","correspondingAuthor":false,"prefix":"","firstName":"Raymond","middleName":"","lastName":"Wen","suffix":""},{"id":436948897,"identity":"fa812c17-746b-4f54-8b42-1287751b47f8","order_by":7,"name":"Jacquie Phillips","email":"","orcid":"","institution":"Murray Primary Health Network","correspondingAuthor":false,"prefix":"","firstName":"Jacquie","middleName":"","lastName":"Phillips","suffix":""},{"id":436948898,"identity":"3593f799-faf7-49ac-a7f3-2a6bdbea46ce","order_by":8,"name":"Mark Ashcroft","email":"","orcid":"","institution":"NCN Health","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Ashcroft","suffix":""}],"badges":[],"createdAt":"2025-03-06 01:16:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6166035/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6166035/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81941484,"identity":"fe2bac1d-d969-4dac-a722-b8b3bdd4ec55","added_by":"auto","created_at":"2025-05-05 07:08:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":173644,"visible":true,"origin":"","legend":"\u003cp\u003eThe Implementation Research Logic Model and the EPIS and CFIR frameworks\u003c/p\u003e","description":"","filename":"Figure1..png","url":"https://assets-eu.researchsquare.com/files/rs-6166035/v1/c7f580efb47224ec339f4774.png"},{"id":81941040,"identity":"e7858ab4-465e-4a06-bf01-56486ab4ab38","added_by":"auto","created_at":"2025-05-05 07:00:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":280472,"visible":true,"origin":"","legend":"\u003cp\u003eThe Implementation Research Logic Model for a virtual medical officer model for rural inpatients\u003c/p\u003e","description":"","filename":"Figure2..png","url":"https://assets-eu.researchsquare.com/files/rs-6166035/v1/82af38e5a8d553971ebfc423.png"},{"id":81942567,"identity":"59dcd4c2-79e8-498f-8fab-fa9cc5dd1971","added_by":"auto","created_at":"2025-05-05 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07:00:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18964,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2..docx","url":"https://assets-eu.researchsquare.com/files/rs-6166035/v1/cd8afcb0ea63785d094459ac.docx"},{"id":81941042,"identity":"1b2c546f-af58-4f4e-80f3-428f17e7e141","added_by":"auto","created_at":"2025-05-05 07:00:29","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":523892,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImage 1. \u003c/strong\u003eCommencing a virtual ward round\u003c/p\u003e","description":"","filename":"Image1..png","url":"https://assets-eu.researchsquare.com/files/rs-6166035/v1/029fc54e8c1e9d287ffb9672.png"},{"id":81941033,"identity":"4be86fc6-a321-461c-8daa-b4ff9bb7acc7","added_by":"auto","created_at":"2025-05-05 07:00:28","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":28408,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"ASSESSReportingTool.docx","url":"https://assets-eu.researchsquare.com/files/rs-6166035/v1/f6c87519b99897f0e40cfccc.docx"}],"financialInterests":"","formattedTitle":"Preparation and implementation factors in rural healthcare innovation: a mixed methods investigation of a virtual medical officer model of inpatient care in Australia","fulltext":[{"header":"Contribution to the literature","content":"\u003cul\u003e\n \u003cli\u003eThis paper highlights the issue of rural medical workforce shortages in Australia.\u003c/li\u003e\n \u003cli\u003eIt reports on an innovative telemedicine strategy that was found to be safe, and acceptable for inpatients and nursing staff, supported local GPs, and is potentially replicable in other rural locations.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIt demonstrates the application of constructs from two implementation frameworks, the Exploration, Preparation Implementation, and Sustainment (EPIS) and Consolidated Framework for Implementation Research (CFIR) to identify influencing factors of preparation for and implementation of this unique telemedicine model.\u003c/li\u003e\n \u003cli\u003eSynthesised findings are presented using the Implementation Research Logic Model (IRLM), illustrating critical features in rural healthcare innovation.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eGlobally, general practitioner workforce availability and community health impacts are concerning issues (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In rural contexts there is a clear juxtaposition between general practitioner (GP) roles and equitable community access to care closer to home (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Virtual models of care have been offered as partial solutions to support GPs and rural populations across Australia (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Guided by implementation science, this paper presents key preparation and implementation factors identified in an evaluation of a unique virtual medical officer inpatient model of care in a rural health service in northern Victoria, Australia.\u003c/p\u003e\n\u003ch3\u003eGeneral practice challenges and the rural GP\u003c/h3\u003e\n\u003cp\u003eThe GP is the pillar of rural primary care which epitomises universal access to effective, efficient and equitable healthcare (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Primary care, as described by the World Health Organization, is the entry point to health services for the identification, treatment and management of most health problems (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In Australia the reported challenges faced by General Practice are largely attributed to increased service demands, current and predicted workforce shortages from retirement and attrition, along with reduced numbers of practitioners attracted to the profession (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In 2023 it was reported that there were 66.2 GPs available per 100,000 people in rural remote areas compared to 122.7 (full-time workload equivalent) in major cities (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). It has been predicted there will be a shortfall of 10,600 (full time equivalent) GPs in Australia by 2031 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRural GP models and roles\u003c/h2\u003e \u003cp\u003eThe prototypical Australian rural GP model of care provides both primary care in the community setting and secondary care in rural hospitals (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This link between general practice and inpatient hospital care is accomplished by the general practitioner visiting medical officer (GP-VMO) role. The GP-VMO involves a local medical practitioner in private practice also providing medical services in a public hospital. It is a fee-for-service contract, and the practitioner must be \u0026lsquo;credentialed\u0026rsquo; by a relevant body to provide in-hospital medical care. In the current context credentialing aligned with Safer Care Victoria policy (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The GP-VMO has similar duties to a \u0026lsquo;hospitalist\u0026rsquo;, a salaried medical officer position that acts as the first point of contact for patients admitted to the hospital and provides overall management of inpatient care (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCare closer to home and telemedicine solutions\u003c/h3\u003e\n\u003cp\u003eCare closer to home is a health system reform vision aiming for safe, high quality healthcare in the right place, at the right time for the right care need (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The rural health service is the spatial connection for care closer to home, assisting local community members to transition through the boundaries between primary and secondary care with referral pathways to tertiary and quaternary care. Rural health services increase access for example, through hosting virtual technology to diagnostic resources and specialists, which then improves rural healthcare equity (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The development of virtual models of care have been championed as innovations to counter geographical inequalities, provide support to local GPs, and enhance continuity of care for rurally located people (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eInnovation and Implementation frameworks\u003c/h3\u003e\n\u003cp\u003eTo investigate innovative models of care as evidence-based, implementation science offers researchers theories and frameworks to support translation into real-world settings (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The use of implementation frameworks is particularly important in the dynamic healthcare environment as compared to the controlled research situation. In rural hospitals, the capacity to examine implementation efforts using these concepts is minimal. In 2023 it was reported that there was a 6.5-billion-dollar deficit in health funding for Australian rural communities (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). More so, overall, there is a lack of rigorous empirical research into innovation implementation in the public hospital system in Victoria, Australia (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Understanding the \u0026lsquo;how\u0026rsquo; of implementation of initiatives such as telemedicine in rural health services, will yield insights into specific facilitators and barriers and contribute to further use of implementation frameworks in such settings.\u003c/p\u003e \u003cp\u003eThe current study is specific to telemedicine-clinical services that provide inpatient-medical practitioner interactions through virtual means in the rural acute ward setting. This paper reports on this innovative model drawing on two well established implementation frameworks; the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework, commonly used in social care settings (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and the Consolidated Framework for Implementation Research (CFIR), used across healthcare settings (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The Implementation Research Logic Model (IRLM) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) was utilised to synthesise and present overall findings. The paper demonstrates how implementation frameworks can be tailored to enhance examination of implementation processes and to identify factors that influence implementation practices (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This investigation is important as there is a lack of research into the factors which lead to effective implementation of virtual health services (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy aims and design\u003c/h2\u003e\n \u003cp\u003eThe aims of the study were to examine the preparation for and implementation of a virtual medical officer clinical service for the rural inpatient setting. The key questions were: 1) What successful and/or challenging features were important facilitators or barriers in the preparation and implementation of the virtual model of care; and 2) To what extent was the virtual model of care efficient and effective in contributing to access to care closer to home for rural people? A mixed methods design was employed, involving a review of processes and documents, electronic quantitative surveys and qualitative interviews. The ASSESS reporting guide (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e), was applied in the preparation of this manuscript due to its suitability as a reporting tool for a mixed methods design, appropriateness for evaluation, it enabled description of both intervention and implementation efforts, along with our objective of synthesising implementation information through combing constructs from different implementation frameworks. The evaluation received ethical approval from the University of Melbourne, Ethics Committee, Office of Research Ethics and Integrity. Reference Number: 2023-25567-36201-4.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy setting\u003c/h2\u003e\n \u003cp\u003eThe study was a collaborative undertaking between the rural health service, the Regional Health Service Partnership (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e), and the local University Department of Rural Health. It involved three campuses of a rural health service in northern Victoria, Australia. The health service provides care to a local population of approximately 30,500 persons covering an area of 4,045 square kilometres (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). The individual populations of the three townships where the health service has a campus located (largest to smallest; figures rounded) are: 6,000; 4,480; and 2,000. At each campus the following number of acute ward beds are available; campus one,16 beds; campus two, 12 beds; and campus three, 6 beds.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eThe innovation: a virtual medical officer model of care\u003c/h3\u003e\n\u003cp\u003eThe innovation was actively piloted at the rural health service from December 2022 to June 2023, it then became embedded as an ongoing service model. The virtual service was introduced to assist with weekend, after-hours medical coverage of inpatients in the three acute wards of the rural health service. It was a unique use of telemedicine developed to be complementary to the usual model involving GP-VMO arrangements. The duties of the virtual medical officer included direct patient consultations, reviewing medications, ordering medical tests (for example X-rays, blood tests), patient admissions into the rural acute wards, updating patient notes and medication orders, discharging patients, issuing prescriptions and providing handover to the patient\u0026rsquo;s usual medical care provider.\u003c/p\u003e\n\u003cp\u003eThe virtual doctor visited inpatients at their bedside through an electronic tablet, as illustrated in Image 1. All interactions were facilitated by a nurse as would occur with a traditional GP-VMO consultation. A leading Australian virtual care business supplied the service, which was founded on the combined experience of medical doctors and technology professionals to provide clinical and software solutions to the healthcare sector (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003ePlace Image 1. about here\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eThe study targeted two groups of participants: 1) health system stakeholders and 2) health consumers. Group one included the rural health service\u0026rsquo;s management and nursing staff, regional health system representatives, local GP-VMOs, and the virtual health care provider\u0026rsquo;s medical practitioners. Group two were patients who had experienced the telemedicine service. An information flyer was available to promote the evaluation, supported by a plain language statement. Individual consent for participation was required.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eData collection\u003c/h2\u003e\n \u003cp\u003eThe processes and documents sourced for the evaluation included project management documents (for example, project plans, minutes of project governance group meetings); health service operational documents such as policies and procedures to guide telemedicine use; resources developed by the health service and telemedicine provider; patient information such as community newsletter articles, health service Facebook posts. In addition, the telemedicine service data for the pilot period was tracked for each campus.\u003c/p\u003e\n \u003cp\u003eResearcher designed surveys for health service nursing staff were managed using REDCap, a secure web application for data capture (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e). Surveys were distributed at two time-points T1: model preparation and T2: model implementation. Surveys were open for two weeks with a reminder sent out at the beginning of week two. The T1 survey included statements about virtual medical officer service awareness, communication, and training. At T2 statements about experiences of the service were added. A 6-point rating scale (1 Very poor to 6 Excellent) was used. At both survey time-points optional free-text comments were invited using open-ended questions about successes and challenges of the model (see Additional file 1 for the complete survey).\u003c/p\u003e\n \u003cp\u003eIndividual interviews for all participants were undertaken over May to June 2023. They took place either face-to-face or through videoconferencing (Zoom or Microsoft Teams) using only the audio recording function. Semi-structured interview questions were developed by researchers. Group one (health system stakeholders), interviews included questions about overall experiences of the telemedicine model, and successful or challenging aspects about the preparation for and implementation of the pilot innovation. Group two (patient) questions asked about feelings of safety, care experienced, and use of virtual inpatient care again (see Additional file 2 for all interview questions).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eA content analysis of processes and documents were undertaken through a deductive approach using constructs from the EPIS (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) and the CFIR (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) implementation frameworks as guiding categories (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e). A table developed in Microsoft Word was utilised to record this information.\u003c/p\u003e\n \u003cp\u003eSurvey data were retrieved from REDCap via a Microsoft Excel spreadsheet. These data were analysed descriptively, and results tabulated for presentation, along with a summary of respondent\u0026rsquo;s free-text comments.\u003c/p\u003e\n \u003cp\u003eAll interview recordings were transcribed by the first author. Participants were assigned a unique identifier to protect anonymity; for example, health system stakeholders were assigned an ID of #HSS01; a patient #P01. Transcripts were analysed by two authors using the Qualitative Framework Approach (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e). This is a stepped method which involves researcher familiarisation with transcripts through reading and re-reading and applying initial codes to passages (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e). Then, through an iterative process, researcher agreed codes were organised into categories for refinement and then interpretation of themes.\u003c/p\u003e\n \u003cp\u003eTo guide triangulation, constructs from the EPIS and the CFIR implementation frameworks were utilised. The IRLM was employed for syntheses and to provide a visual representation of implementation efforts and associated change mechanisms; it also assisted with combining implementation framework components (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e). An adapted conceptual depiction of the IRLM (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) is shown in Fig. 1, noting key elements from the EPIS and CFIR, implementation frameworks.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003ePlace Fig.\u0026nbsp;1. about here\u003c/h2\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe results commence with a summary of the telemedicine service data tracked for the pilot period and provided in Table\u0026nbsp;1. It is notable that during the pilot no clinical incidents were recorded and no patients required escalation of care to a large regional centre. The process and document review are presented next, these are followed by survey results and then findings from the analyses of interview transcripts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;1.\u003c/strong\u003e Telemedicine inpatient service data December 2022 to June 2023\u003c/p\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003ePlace Table\u0026nbsp;1. about here\u003c/h2\u003e\n \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\n \u003ch2\u003eProcess and document review\u003c/h2\u003e\n \u003cp\u003ePresented in Table\u0026nbsp;2 are the results from the process and document review which have been classified using the four phases of the EPIS (column 1), followed by the strategies identified from the analysis (column 2), and then aligned to the implementation constructs of the EPIS and the CFIR (column 3), finally a description of the associated evidence and actions are provided (column 4).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2.\u003c/strong\u003e Summary of process and document review results aligned to implementation constructs\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003ePlace Table\u0026nbsp;2. about here\u003c/h2\u003e\n \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\n \u003ch2\u003eHealth service nursing staff survey\u003c/h2\u003e\n \u003cp\u003eAt the preparation phase (T1), n\u0026thinsp;=\u0026thinsp;15 nursing staff responded to the survey, and at implementation phase (T2) six nurses took part. The lower number of responses at implementation reflects completion of the survey by nurses who had direct experience of the telemedicine model and were on duty when the service was active. In summary, nursing staff showed high awareness (93%) of the model introduction at preparation and very good-to excellent ratings for quality of care (100%) at implementation. Survey questions and results are provided in Additional file 1. Leadership at the rural health service believed that a specific examination of rural nurse impact when implementing virtual inpatient care was warranted and these results have been reported elsewhere (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eInterview findings\u003c/h2\u003e\n \u003cp\u003eOverall, 77 participants were involved in interviews; Group one (n\u0026thinsp;=\u0026thinsp;39); Group two (n\u0026thinsp;=\u0026thinsp;38). Characteristics of each group are described in Table\u0026nbsp;3; thematic findings are then provided.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;3.\u003c/strong\u003e Interview participant characteristics, Group one (HSS) and Group two (P)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003ePlace Table\u0026nbsp;3. about here\u003c/h2\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003eInterview themes\u003c/h2\u003e\n \u003cp\u003eFindings are presented under three themes and subthemes with example quotes. As occurred with the document review (see Table\u0026nbsp;2) alignment with the phases of the EPIS Framework have been identified, and constructs from both the EPIS and CFIR are included.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003e\u003cstrong\u003eTheme 1. Facilitators of the telemedicine model\u003c/strong\u003e\u003c/h2\u003e\n \u003cp\u003eAll participant views indicated overall high satisfaction with introducing the virtual model of care for the acute ward. The successful aspects of the pilot are grouped into four subthemes with supporting quotes.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eSubtheme 1.1 Understanding the context, problem and solution\u003c/h2\u003e\n \u003cp\u003eThis subtheme aligns to the EPIS Exploration stage, and the construct of Innovation Relative Advantage (CFIR). Stakeholders articulated the need for healthcare service delivery improvement. They had a thorough understanding of the need, potential solution and the case for change, as exampled by a participant quote,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThe project has been a way to provide medical cover in the ward. This has come at a time when we are really facing care not being delivered due to the decreasing GP workforce in rural health services\u003c/em\u003e. (#HSS04)\u003c/p\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003eSubtheme 1.2 Scope, negotiation and support to execute change\u003c/h2\u003e\n \u003cp\u003eThis subtheme shows the connections between the EPIS Exploration and Preparation phases. It highlights the features that firstly, assisted to prepare for change and then, aided in the implementation. These included resource support of personnel, funding, and project planning and management aspects, as acknowledged by the following,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSetting the project up to succeed about what was its scope, what were we trying to achieve, how we\u0026apos;re trying to achieve it.\u003c/em\u003e (#HSS11)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI think having project resources, with the project lead, has been instrumental in its successes as you have got someone to coordinate the effort.\u003c/em\u003e (#HSS01)\u003c/p\u003e\n \u003cp\u003eIn addition, it provides an example of partnerships and connections (CFIR). The negotiations which assist with planning to introduce change were vital, as one stakeholder stated,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eWe were able to pre-emptively solve a lot of problems before they came up. The feedback allowed us to design the technology and the service so that we had already anticipated many of the streams and the content of the communication that was required to be able to run the service\u003c/em\u003e. (#HSS05)\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n \u003ch2\u003eSubtheme 1.3 Successful interactions through engagement, relationships, and communication\u003c/h2\u003e\n \u003cp\u003eThis subtheme demonstrates the Relational Connections across the Inner Context/Setting and Outer Context/Setting (EPIS and CFIR). The importance of connecting at different levels and by various means was stressed by interviewees. The professional interactions highlighted the importance of building engagement from the beginning,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI think stakeholder engagement is a very key and integral part of rolling out a new model of care like this\u003c/em\u003e. (#HSS06)\u003c/p\u003e\n \u003cp\u003eThe care interactions emphasised sensitivity and responsive communication by the virtual care provider and highlighted respect for staff and patients. Two examples are given,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eA very positive aspect is the\u003c/em\u003e [provider name] \u003cem\u003edoctor is happy to engage with\u003c/em\u003e [nursing] \u003cem\u003estaff and happy to listen and act upon our concerns.\u003c/em\u003e (#HSS12)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThe patients appeared to feel that somebody had more than a couple of minutes to spend with them. It helps that\u003c/em\u003e [doctor name] \u003cem\u003ehas got a really good bedside manner. He has patience and he listens, and he\u0026apos;s interested. That was nice.\u003c/em\u003e (HSS#07)\u003c/p\u003e\n \u003cp\u003ePatient\u0026rsquo;s experiences highlighted how communication facilitated the doctor-patient relationship and there were observations about positive relationship building with nurses, as these following excerpts exemplify,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eDoctor\u003c/em\u003e [name] \u003cem\u003ewas very professional but down to earth\u003c/em\u003e (#P09); \u003cem\u003eDoctor\u003c/em\u003e [name] \u003cem\u003ereally listened to me and my needs, he really cared and helped me.\u003c/em\u003e (#P13) and, \u003cem\u003eDoctor\u003c/em\u003e [name] \u003cem\u003ewas great to deal with, he seemed to get on with the nurses\u003c/em\u003e. (#P29)\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n \u003ch2\u003eSubtheme 1.4 Impact on care, people, and place\u003c/h2\u003e\n \u003cp\u003eThis subtheme captures the EPIS Implementation Stage and areas of acceptability, satisfaction efficiency, and effectiveness (EPIS and CFIR). There were positive impacts on care, people and place. Patients overwhelmingly confirmed feelings of safety, care was as it should be, and they would use the virtual service again. Descriptions were provided about the positive impact of access to care and highlights the importance of the provision of care over the weekend or out of hours within the rural acute ward. Patients commented that they appreciated the health service making this service available, it was also indicated that carer stress was reduced due to this service access, for example,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI felt relieved that a doctor would be reviewing him\u003c/em\u003e [husband] \u003cem\u003eover the weekend.\u003c/em\u003e (#P05)\u003c/p\u003e\n \u003cp\u003eCare efficiencies were accentuated by processes, such as access to electronic medication charts. As stated by an interviewee,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAn electronic medication chart, limits the risk of transcribing issues etcetera and makes it really clear and accurate for staff to use.\u003c/em\u003e (#HSS10)\u003c/p\u003e\n \u003cp\u003eEffectiveness of access to care closer to home was highlighted by perceptions about the impact for patients, for example,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eEveryone likes to come back to their local health service, to their own hometown. We normally wouldn\u0026rsquo;t have that capacity to take patients back over the weekend; with\u003c/em\u003e [name of telemedicine service] \u003cem\u003ewe now have that flexibility.\u003c/em\u003e (#HSS02)\u003c/p\u003e\n \u003cp\u003eThe impact on GPs considered the current and ongoing situation, as this next excerpt highlighted,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eGood for GPs to have a break, especially as we have less GPs doing on call. We don\u0026rsquo;t want to lose anymore GP\u0026rsquo;s.\u003c/em\u003e (#HSS12)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 2. Barriers to the telemedicine model\u003c/h2\u003e\n \u003cp\u003eThe barriers identified by stakeholders were not seen as negatives or an indication that the telemedicine model was flawed but rather, there were things that arose which needed to be addressed. There were three subthemes which emerged that relate to Bridging and Innovation factors to assist with barriers and challenges (EPIS).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\n \u003ch2\u003eSubtheme 2.1 Challenges in adjusting the traditional inpatient model of care\u003c/h2\u003e\n \u003cp\u003eThe consideration of the effects on health service staff, particularly nurses and local GP-VMOs, and the traditional inpatient model of care in the acute ward was important. The changes required adjustments to their workload, the first example is about GPs and the second relates to nurses,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSometimes we are busy and can\u0026rsquo;t communicate or give a handover to the telemedicine doctor.\u003c/em\u003e (#HSS29)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIt was time consuming. By adding in doctors\u0026rsquo; rounds on weekends, this was an increased workload. Spending over an hour doing a doctor\u0026apos;s round that we had never done before.\u003c/em\u003e (#HSS07)\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSubtheme 2.2 Challenges in managing perceptions\u003c/h3\u003e\n\u003cp\u003eAn area that was repeated in several of the interviews was the nature of the virtual model of care and cautioning that it is not a replacement service, nor should it inadvertently be a means to ignore disadvantage or access and equity issues. Highlighted was the importance of negotiations during the EPIS Exploration stage, as phrased by interviewees,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn our discussions with our GPs and VMOs about\u003c/em\u003e [name of telemedicine service] \u003cem\u003eand the service offered, being very mindful that we are not trying to take business away from them, we are just trying to add a complementary service in to work alongside our existing GPs\u003c/em\u003e. (#HSS10)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s about supporting the local GPs, not substituting their care. And not substituting them on the rosters.\u003c/em\u003e (#HSS31)\u003c/p\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\n \u003ch2\u003eSubtheme 2.3 Challenges posed by complacency\u003c/h2\u003e\n \u003cp\u003eThis subtheme drew on interview content that alluded to the healthcare setting not becoming complacent in seeking feedback and engaging in continuous quality improvement. It was seen as essential that regular and ongoing updates about all aspects of the model is actively sought, and that patients remain a priority,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIt\u0026rsquo;s important we are learning from all feedback; what are we learning from the model; what are we learning from the good experiences and the not so good experiences. Also, are we undertaking any follow-up studies for example, monitoring of patient\u0026rsquo;s care and their engagement with the health care system.\u003c/em\u003e (#HSS21)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 3. Sustaining telemedicine innovation gains for the future of rural healthcare\u003c/h2\u003e\n \u003cp\u003eParticipants were cognisant that the pilot was successful but aware there are broader ongoing challenges facing rural and regional areas. It is relevant to the EPIS Sustainment stage. The findings from this overarching theme were grouped into three subthemes with exemplifying quotes.\u003c/p\u003e\n \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\n \u003ch2\u003eSubtheme 3.1 Caring for the rural population and the rural workforce\u003c/h2\u003e\n \u003cp\u003eThis subtheme is indicative of Innovation Outcomes (CFIR) and connects to quality of life for the rural population and workforce. It shows that caring for those living and working rurally is interdependent, as shown by the next two quotes,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIt\u0026rsquo;s reassuring that patients are being looked after over the weekend.\u003c/em\u003e (#HSS28) \u003cem\u003eAs long as patients are happy, I am happy.\u003c/em\u003e (#HSS27)\u003c/p\u003e\n \u003cp\u003ePatients indicated they valued the continuity of care offered by their local GP and were concerned about the loss of the local healthcare workforce. It was emphasised by patients that they preferred their own local doctor, and some felt the virtual service was not as personal as having an in-person doctor consultation. However, it was also acknowledged that to retain the local GP workforce they need support, and this type of service would provide them with a break.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\n \u003ch2\u003eSubtheme 3.2 Sustainability and replicating the telemedicine model\u003c/h2\u003e\n \u003cp\u003eThis subtheme exemplifies the Sustainment stage (EPIS) whereby consideration of long-term determinants is key. There was an understanding that rural healthcare needs are continuous and likely to increase, and a skilled and viable workforce is essential. The following excerpt highlights these opinions,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThat agility will become more important with not only the medical workforce but the clinical workforce as we become more and more challenged in rural areas. We need sustainability with care for an ageing population, more chronic disease and so forth. We need to look at different ways of doing things.\u003c/em\u003e (#HSS04)\u003c/p\u003e\n \u003cp\u003eStakeholders felt a responsibility to continue to embed and improve the telemedicine model and to ensure that the experiences of this rural health service initiative are more widely available, as this next quote exemplifies,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePart of the role of the partnership is scale, sharing expertise, the project coordination. It\u0026apos;s about where the scale, the processes and coordination and the shared expertise goes with this pilot.\u003c/em\u003e (#HSS11)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003eSubtheme 3.3 The need for a rural digital health strategy\u003c/h3\u003e\n\u003cp\u003eThis subtheme reflects the influence of the Outer Context/Setting (EPIS and CFIR) the determinants of which can be mediators or moderators of innovation. The policy environment was evident as an area in which to advocate for innovative models of care for the rural healthcare context, such as this inpatient virtual medical officer service, as explained by an interviewee,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe persistent shortage of staffing in the regional areas and working in this industry for the past years and dealing with different specialties, we believe that we wouldn\u0026apos;t have a quick cure. So, we have to embrace a complementary model as part of the public health strategy in the future. A digital health strategy and partnerships to better utilize specialists\u0026rsquo; capacity.\u003c/em\u003e (#HSS26)\u003c/p\u003e\n\u003ch3\u003eTriangulation and synthesis of all results\u003c/h3\u003e\n\u003cp\u003eTo bring together the mixed methods study results, triangulation was undertaken and then synthesised as a visual representation. Triangulated results are provided descriptively in Table\u0026nbsp;4 under the four domains of the IRLM (see Fig.\u0026nbsp;1). As previously stated, this was guided by two implementation frameworks (EPIS and CFIR). The synthesised findings are depicted in Fig.\u0026nbsp;2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;4.\u003c/strong\u003e Results of triangulation\u003c/p\u003e\n\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\n \u003ch2\u003ePlace Table 4. about here\u003c/h2\u003e\n \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\n \u003ch2\u003ePlace Fig.\u0026nbsp;2. about here\u003c/h2\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated preparation and implementation factors for a virtual medical officer model of care for clinical services in three acute wards at a rural health service in northern Victoria, Australia. We aligned the results to constructs from two implementation science frameworks, the EPIS and CFIR, to highlight key factors of innovation implementation. The synthesised findings were presented using the IRLM. Our discussion reflects on the important features identified from this analytical process that promote successful implementation and may encourage the further use of implementation frameworks.\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section2\"\u003e \u003ch2\u003ePreparation factors\u003c/h2\u003e \u003cp\u003eThe reporting of preparation factors when introducing healthcare innovations is limited. As revealed by a systematic review by Moullin, Dickson (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) of 49 included implementation research studies, 14 were explicit about exploration and 18 about preparation. Similarly, Powell, Patel (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) stressed the critical nature of attending to these early stages to ensure innovation feasibility and implementation success. Our study has emphasised the significance of exploring and preparing for innovation implementation. It has identified that factors such as detailed attention given to understand the contextually specific antecedents which influence the problem and consideration of the evidence to develop a solution, ensure a viable platform to introduce the innovation. In addition, early use of a systematic strategic approach was enabling throughout implementation (as described in Table\u0026nbsp;2 and illustrated in Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eThe synthesised findings showed that exploration was extensive but seamlessly joined with preparation and the design of the innovation. This accentuated the relational culture of design negotiation between stakeholders. Research has identified that health interventions can fail due to poor design and/or implementation (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The design of the virtual medical officer model of care was achieved through the relational mechanisms of leadership, collaboration and partnership. These were individual characteristics but also organisational characteristics amongst the negotiating stakeholders, i.e. the rural health service, the telemedicine provider and the Regional Health Service Partnership. In addition, this factor was seen to positively influence translation and dissemination in the sustainment stage.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplementation factors\u003c/h3\u003e\n\u003cp\u003eA feature which supported transition from preparation to implementation was the project management strategy that was supported by resourcing with funding and knowledge and skills. As detailed in Fig.\u0026nbsp;2, this strategy embedded delivery systems, supported the team and individuals and enabled change management. As described by implementation science researchers an implementation strategy defined through actor and action mechanisms can overcome barriers and activate facilitators (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Our study provides pragmatic descriptions of the link between the project management strategy, mechanisms, outcomes and functions of bridging and innovation factors, and captures these in our virtual medical officer model of care IRLM descriptors (see Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eIn addition, the implementation factor of project management was a critical mechanism in the capacity for adjustment of the model. This involved incorporating active feedback loops. This mechanism, whereby nurse and patient experiences were acted upon and adjustments made to the model of care in \u0026lsquo;real time\u0026rsquo; (described in Table\u0026nbsp;2), highlighted the adaptable elements. The identification of this factor shows how the specific nuances of context informed the modification to the model of care but did not alter the core elements of the innovation design developed from evidence (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Further, this is significant as it can inform planning for intervention insertion into other contexts for replication or scalability (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eCombining implementation frameworks\u003c/h3\u003e\n\u003cp\u003eWe sought to present novel insights from the evaluation data by using constructs from the EPIS and CFIR and then synthesising the information graphically through the IRLM, as an organising framework (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The rationale was to examine the multileveled and multidimensional nature of rural innovation and identify the distinct features which may contribute to implementation success. The possibilities in combing implementation frameworks are recognised in the literature as assisting with gaps and increasing the breadth and depth of analysis (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). However, researchers also suggest that using multiple frameworks can result in unnecessary complexity (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur use of the frameworks has highlighted the importance of understanding the different phases of implementation (EPIS), particularly how exploration and preparation are essential platforms to transition to subsequent stages for successful implementation. In addition, the EPIS was beneficial when considering bridging and innovation factors and how these assisted with navigating the boundaries between contexts or settings. The CFIR was helpful in identifying the determinants of implementation in healthcare; and this is the most commonly cited reason for using a framework (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Used in our analyses it emphasised the importance of defining constructs within domains to ensure the framework is relevant to the site of implementation. As recommended by Damschroder, Reardon (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), subjects of domains should be defined and specific language, appropriate for the implementation situation, used to describe constructs. Both frameworks were valuable to identify nuances about context (EPIS) or settings (CFIR); these terms are complimentary and perhaps interchangeable, as found by the review by Watson, Adams (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). We suggest, that for rural healthcare research about innovation implementation they should be uniquely described. Particularly, as in the current study, the rural synergies between primary care and tertiary care are very different to urban models of care.\u003c/p\u003e \u003cp\u003eDescriptions of \u0026lsquo;outer context\u0026rsquo; for rural healthcare researchers emphasise the spatial connections of people and place along with geographical features of location regarding access, equity and the social determinants of health (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). \u0026lsquo;Inner context\u0026rsquo; is helpful to describe for example, workforce culture, where rurally this is often influenced by historical and generational relationships with patients and their families which can influence knowledge, attitude and behaviour when introducing practice change (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In contrast, in defining \u0026lsquo;outer settings\u0026rsquo; this may showcase for example, the policy and legal climate, the complexities of national and state funded healthcare systems, and healthcare workforce strategies (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). \u0026lsquo;Inner setting\u0026rsquo; can describe resource availability, educational requirements and as evidenced by Fernandez, Walker (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), are important to recognise implementation influences at the clinical level. Nuanced lenses about context and settings would increase insights into the multidimensional (macro to micro) features of implementation and the identification of facilitators and barriers as we have indicated in Fig.\u0026nbsp;2.\u003c/p\u003e \u003cp\u003ePresenting our synthesised findings by using the IRLM was effective in distilling the evaluation information (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). This logic modelling approach (see Fig.\u0026nbsp;2) showed the connections between strategies and mechanisms and emphasised causal pathways, which together support the translation of evidence to practice (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Its utility in succinctly presenting information would encourage further use of implementation frameworks by any healthcare discipline.\u003c/p\u003e\n\u003ch3\u003ePolicy implications\u003c/h3\u003e\n\u003cp\u003eThis study has policy implications for the development of rural medical workforce strategies and the planning of a rural digital healthcare strategy. The virtual medical officer model of care for the rural acute ward was designed to provide professional support to local GPs, relieve role burden and to be complementary to existing arrangements. A principle noted in the Victorian Department of Health\u0026rsquo;s virtual care strategy, although not specific to rural General Practice, is the use of virtual care to be a complementary tool (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). As we have identified, it is critical that virtual models are not used as replacement services or inadvertently become a means to ignore disadvantage or access issues. Further, it is essential that rural patients\u0026rsquo; needs and preferences are acknowledged and appropriately met, and service delivery innovations remain sensitive to patients at the centre of care. Ongoing considerations concern continued vigilance about healthcare equity for rural communities.\u003c/p\u003e\n\u003ch3\u003eStudy limitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations which must be acknowledged. The evaluation was time-limited to the pilot of the virtual medical officer model of care, a gap is the lack of a monitoring phase to measure ongoing impact and collect evidence about changes in the model over time. The innovation was introduced at an individual rural health service in a single geographic area of Australia, serving patients who are elderly (over 65 years). Hence, there was relatively limited diverse representation in terms of rurality, age and cultural diversity, limiting the evaluation outcomes generalisability. However, some of the characteristics described are common in rural settings and this supports the model as being replicable in other locations, particularly for rural inpatient services experiencing GP-VMO workforce shortages. In addition, authors acknowledge that further research is essential to investigate the economic factors associated with this model of care and the impact on workforce outcomes for rural GPs.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, participants (nurses, GPs, health system representatives, the virtual provider and patients), were positive about the introduction of the virtual model of care. The evaluation found the model to be acceptable, satisfaction was high and helpful outcomes were achieved, as identified by IRLM outcome categories. The IRLM provided an example of the versatility of this diagrammatic representation, its practicability in combining elements from two implementation frameworks, and assisted with highlighting the application of the innovation to practice. The importance of pre-preparation, preparation and implementation factors highlighted from our study will aid decision makers when negotiating, designing and introducing rural healthcare innovations.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFIR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsolidated Framework Implementation Research\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExploration Preparation, Implementation, Sustainment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIRLM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImplementation Research Logic Model\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVMO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisiting Medical Officer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation received approval from the University of Melbourne, Ethics Committee, Office of Research Ethics and Integrity. Reference Number: 2023-25567-36201-4.\u0026nbsp;Participation in the study was voluntary, and no incentives were offered to any participant group. Consent was obtained from each participant prior to all data collection activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent was received for the individual\u0026rsquo;s image (Image 1) included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNursing staff survey questions and all results are available in Additional file 1. Interview questions for both participant groups are available in Additional file 2. All other materials are available on specific request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors, CS and RW, are part of the Telecare Australia Pty., Ltd, group who were the providers of the telemedicine service but were not involved in any data collection, data analysis, synthesis, or conclusion development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was provided for the research reported and in the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthorships\u0026rsquo; contribution\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCR:\u003c/strong\u003e study protocol development, ethics application, data collection, analysis and interpretation of findings, first draft of manuscript, subsequent refinement and editing of paper. \u003cstrong\u003eCC:\u003c/strong\u003e study protocol development, data collection, analysis and interpretation of findings, reviewing and editing of paper. \u003cstrong\u003eVJ:\u003c/strong\u003e data collection and analysis, reviewing and editing of paper.\u0026nbsp;\u003cstrong\u003eKCT\u003c/strong\u003e: topic area expertise, reviewing, and editing of paper. \u003cstrong\u003eAF:\u003c/strong\u003e reviewing and editing of paper. \u003cstrong\u003eCS:\u003c/strong\u003e \u003csup\u003e\u0026nbsp;\u003c/sup\u003etopic area expertise, reviewing, and editing of paper.\u0026nbsp;\u003cstrong\u003eRW:\u003c/strong\u003e topic area expertise, reviewing, and editing of paper.\u0026nbsp;\u003cstrong\u003eJP:\u003c/strong\u003e reviewing and\u0026nbsp;editing of paper. \u003cstrong\u003eMA:\u003c/strong\u003e Implementation framework expertise, reviewing, and editing of paper.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was undertaken on the unceded lands of the Yorta Yorta Peoples. The authors acknowledge the Traditional owners of the land and pay our respects to all Elders past and present.\u003c/p\u003e\n\u003cp\u003eThe project acknowledges the Australian Government Department of Health and Aged Care Rural Health Multidisciplinary Training programme.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional File 1. Nursing staff electronic survey\u003c/p\u003e\n\u003cp\u003eAdditional File 2. Semi structured interview questions\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKaruna C, Palmer V, Scott A, Gunn J. Prevalence of burnout among GPs: a systematic review and meta-analysis. 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A structural equation model of CFIR inner and outer setting constructs, organization characteristics, and national DPP enrollment. Implement Sci Commun. 2023;4(142):1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s43058-023-00522-3\u003c/span\u003e\u003cspan address=\"10.1186/s43058-023-00522-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandez ME, Walker TJ, Weiner BJ, Calo WA, Liang S, Risendal B, et al. Developing measures to assess constructs from the inner setting domain of the consolidated framework for implementation research. Implement Sci. 2018;13(1):1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13012-018-0736-7\u003c/span\u003e\u003cspan address=\"10.1186/s13012-018-0736-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Telemedicine inpatient service data December 2022 to June 2023\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCampus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWard rounds\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient consultations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew admissions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeekends serviced\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransfers to acute hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eCampus one\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eCampus two\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eCampus three\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eTOTALS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110px;\"\u003e\n \u003cp\u003e383\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Summary of process and document review results aligned to implementation constructs\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"926\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cem\u003eColumn 1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cem\u003eColumn 2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003eColumn 3\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 519px;\"\u003e\n \u003cp\u003e\u003cem\u003eColumn 4\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation stage (EPIS) and timeframe\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrategies\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation constructs (EPIS and CFIR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 519px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eassociated evidence and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eactions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eEXPLORATION PHASE\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e2021 Health service strategic plan, identified care\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u003cem\u003eClose to Home\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;as a priority pillar\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOctober 2022 negotiation about a virtual VMO model of care was underway\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eProblem identification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAntecedents (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eConcerns were raised about local GP workforce burnout. Tracking from 2017 to 2023 of local GP numbers revealed a 75 percent reduction in on-call availability to attend to patients in the rural acute wards.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cu\u003eLocal rural health service situation:\u003c/u\u003e acute beds available, with limited admissions capacity and capability. Unable to accept acute ward admissions due to lack of VMO availability.\u003c/p\u003e\n \u003cp\u003e\u003cu\u003eTertiary regional health service situation:\u003c/u\u003e high demand and internal bed pressures, impact on workforce and other resources, impacting patient flow. Too many admissions for health service capacity.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eSolution identification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAntecedents (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eVirtual services were flagged among potential solutions. There was an opportunity to develop a virtual model of care, which offered additional (off-site) Medical Officer capacity.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eSystematic, strategic approach\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eImplementation methods\u003c/p\u003e\n \u003cp\u003e(EPIS \u0026amp; CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eA systematic, strategic approach was enabled through the Regional Health Service Partnership (Victorian Government, 2021). This entity works in collaboration with members to advance strategic system priorities determined by government and local priorities agreed upon by members.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIntervention identification\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEvidence-based innovations (EPIS \u0026amp; CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eThe success of virtual services for local urgent care needs such as,\u003cem\u003e\u0026nbsp;My Emergency Doctor\u003c/em\u003e (My Emergency Doctor, 2024) and the Victorian Virtual Emergency Department (VVED) (Northern Health, 2022), highlighted models which relieved rural GP-VMO on-site attendance.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNegotiation with intervention providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBridging factors between the inner and outer contexts (EPIS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eOriginally, the telemedicine provider was exploring business opportunities. Their initial models were based on outpatients in rural areas using telemedicine to assess a whole range of medical specialists for non-urgent consultations. That was not the need, and the volume for that type of clinical activity wasn\u0026rsquo;t viable in the rural location.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIntervention design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInnovation factors characteristics of the intervention \u0026amp; the developers (EPIS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eA series of discussions with the telemedicine provider began. This was to explore their interest in using their telemedicine platform to support other clinical activity, which is more voluminous and regular, and in greater need of support at the rural health service. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe virtual Medical Officer model of care for clinical services in the rural acute ward began to emerge; it was to be complementary to the existing local GP-VMO \u0026ldquo;traditional\u0026rdquo; care arrangements.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIntervention system alignment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOuter context \u0026amp; bridging factors (EPIS)\u003c/p\u003e\n \u003cp\u003eOuter setting (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eAn extended process occurred to convince the public health system structure to consider alternative models of care such as this, including directors of medical and clinical services. The complexities of virtual health care, and the interface between private provider models and the public healthcare system were highlighted in the review of all documents for the evaluation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePREPARATION PHASE\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOctober 2022 to December 2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eEstablishing partnerships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eThe boundary between the Inner Setting and Outer Setting (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eThe proposal for this model of care was presented to the Regional Health Service Partnership, a CEO Council of 15 health services across the region\u0026nbsp;(Victorian Government, 2021). The briefing paper to CEOs informed all stakeholders, assisted with engagement and partnership connections, secured project management funding and established roles and responsibilities for the pilot.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eProject management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eIndividuals domain (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eProject management was initiated in order to facilitate a change management process. A project lead was appointed, project governance established (e.g. reporting lines, communication, Terms of Reference) and members appointed for a project working group.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eLegal contract\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOuter Setting domain (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eContract negotiations commenced between the telemedicine provider and the health service and its legal representative. It was envisaged that the contract template could be replicated if additional rural health services wished to implement this telemedicine model.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eDocumentation development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInner setting domain (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eA suite of model of care, management and operational documents were developed. An example operational document was the \u003cem\u003eHealth service procedure on telemedicine use\u0026nbsp;\u003c/em\u003eto provide guidance and advice to nursing staff about the use of the virtual doctor service. This procedure included admission criteria and exclusion criteria.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCommunication resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInner setting domain (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003ePatient and staff information material was developed, distributed, and reviewed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIntervention knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInner setting domain (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eStaff education and training were developed, offered and conducted at all health service campuses.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIntervention provider credentialing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOuter context (EPIS)\u003c/p\u003e\n \u003cp\u003eOuter Setting domain (CFIR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eThe telemedicine, medical practitioners undertook credentialing in accordance with the Safer Care Victoria Medical Credentialing and Scope of Clinical Practice Policy (Safer Care Victoria, 2023). This is a compliance requirement to provide independent medical services to hospitals in Victoria. Comparable credentialling is required in all states and territories of Australia.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eIMPLEMENTATION PHASE\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eDecember 2022, service goes live; February 2023 model operational at all three health service campuses\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAdaptations and problems solving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInner setting domain, innovation factors (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eDuring implementation iterative review and adjustments were made to enable re-orientation in-situ. Throughout the pilot feedback was tracked to identify issues and then problem solving occurred to arrive at viable solutions. Examples are reviewing the patient criteria for virtual doctor use and adjustments to the nursing routine in the wards.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eQuality of care processes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInner setting domain (CFIR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003eHealth service processes for clinical review were imbedded during the pilot to ensure the safety and well-being of all patients receiving the intervention and health care staff involved with delivery. The process for clinical review followed current procedures where anything that would normally meet a trigger for clinical reviews would be included, e.g., unplanned transfers out, adverse events such as falls, Hospital Acquired Complications (HAC).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eSUSTAINMENT PHASE\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e2024 - ongoing\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePost intervention pilot scalability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBridging factors between the inner and outer contexts (EPIS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 519px;\"\u003e\n \u003cp\u003ePost-pilot, the continuation of the model has been successful. The evaluation provided evidence which supported its efficiency, effectiveness and safety. In addition, scalability options and adaptation and further development were considered with the creation of generic document packs, ready for specific health service branding to enable use by other health services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 926px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e CFIR \u0026ndash; Consolidated Framework for Implementation; EPIS-Exploration, Preparation, Implementation framework; GP-General Practitioner; VMO-Visiting Medical Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Interview participant characteristics, Group one (HSS) and Group two (P)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterviews\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eGroup one, health system stakeholder (HSS) characteristics\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eThere were 51 stakeholders invited to take part, 39 accepted.\u0026nbsp;Interviews ranged from 30 to 60 minutes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003eHSS participants were n = 25 (64%) females, and n = 14 (36%) males. Interview participant subgroups were, health service staff including management and nurses (n = 24); regional health system representatives (n = 9), GPs-VMOs (n = 3), and the virtual health care provider\u0026rsquo;s physicians (n = 3).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eGroup two, patient (P) characteristics\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eInterviews ranged from 10 to 20 minutes and were undertaken whilst patients were still on the ward.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 356px;\"\u003e\n \u003cp\u003ePatient interviews involved females n = 21 (55%) and males n = 17 (45%). The age range was 64 to 91 years, with 36 participants (94%) over 65 years, grouped into age categories this equated to 65 to 74 years, n = 8 (21%); 75 to 85 years, n = 10 (26%); and 85 years plus, n = 18 (47%). \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Results of triangulation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRLM\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Domain 1. Determinants\u003c/strong\u003e \u0026ndash; aspects which may be barriers or facilitators\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eIntervention characteristics: the \u0026lsquo;thing\u0026rsquo; (a telemedicine model of care for the rural acute ward setting) being implemented.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eBarriers:\u003c/em\u003e the innovation design required extensive negotiation at the exploration stage to develop a contextually relevant model that was safe, provided high-quality care and was patient centred; the model is reliant upon technology, and this could be a moderator to its efficiency and effectiveness due to inherent issues often exacerbated by the rural location, such as internet interruptions, slow connections and delayed/blocked email communications.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eFacilitators:\u003c/em\u003e published evidence about the success of other telehealth models; precedents with other telemedicine models in use; robust track record of the telemedicine provider; the enhanced adaptability of the model as negotiated between all stakeholders; the appropriateness of the innovation pilot given the evidence about need and the case for change (i.e. to a virtual VMO model of care).\u003c/li\u003e\n \u003cli\u003eInner setting: the rural context of the innovation, including the health service and community served along with the teams involved with the pilot.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eBarriers:\u003c/em\u003e various understandings about the model and the complex work involved in educating all systems and stakeholders; translation of the model into practice.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eFacilitators:\u003c/em\u003e access to project management resourcing and the appointment of a project lead to effectively mediate the barriers to achieve translation to practice.\u003c/li\u003e\n \u003cli\u003eOuter setting: the broader context which influenced the implementation of the innovation (model of care), such as the socio-political environment inclusive of legislation, government healthcare policy.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eBarriers:\u003c/em\u003e dissonance between the public health system and private health sector models.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eFacilitators:\u003c/em\u003e the critical linkages between the inner and outer setting boundaries were provided by the Regional Health Service Partnership (i.e. CEO council of 15 regional health services); the collaborative approaches to comply with public health system requirements, for example credentialing of telemedicine medical practitioners.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIndividual characteristics: the inner and outer setting roles and responsibilities of all stakeholders.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eBarriers:\u003c/em\u003e various predicted and unknown moderators to stakeholder acceptance of the innovation (virtual VMO model of care), for example attitude to changes to the traditional model of care.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eFacilitators\u003c/em\u003e: multi-level leadership (e.g. executive decision makers, subject matter experts, project lead\u0026rsquo;s translation to practice skills), was evident at all stages of implementation; in addition, a relational culture of partnership and collaboration and transparent negotiation between all stakeholders.\u003c/li\u003e\n \u003cli\u003eProcesses: the support activities to apply the innovation\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eBarriers\u003c/em\u003e: resource availability; effectiveness of communication activities (e.g. acute ward nurse uptake of education; reach of community/patient information).\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eFacilitators:\u003c/em\u003e development of community messaging; health service policy regarding telemedicine usage; embedding of evaluation into the pilot.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRLM Domain 2. Implementation strategies\u003c/strong\u003e \u0026ndash; the methods used to transfer evidence into practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePreparation factors: the methods associated with exploration and preparation for the innovation.\u003c/li\u003e\n \u003cli\u003eAssessment of the climate and readiness for change: this strategy encompassed knowledge of place and history. Clear understanding of the rural context, the problem and need. Willingness to brainstorm and advocate for an appropriate and acceptable solution. Engaging a range of stakeholders in planning of the innovation. A multidisciplinary approach taken to develop the model of care.\u003c/li\u003e\n \u003cli\u003eImplementation factors: the methods associated with activating the innovation into practice.\u003c/li\u003e\n \u003cli\u003eUndertaking a project management approach to implement the innovation: this strategy connected processes and people (e.g., local GPs, virtual medical practitioners, nursing staff, patients), and enhanced pilot feasibility and compatibility of the new model of care for insertion into the inner (rural acute ward) setting.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRLM Domain 3. Mechanisms\u003c/strong\u003e \u0026ndash; the detailed components of implementation strategies which steps out the actions to link to cause and affect\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBridging factors: assist to navigate the boundaries between the inner and outer contexts.\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eRelational approaches were key bridging factors, including innovative leadership, trusted leaders, ongoing negotiation, transparent collaboration and strong partnerships.\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eInnovation factors: assist with flexibility or adaptability of the innovation to maximise its contextual fit.\u003c/li\u003e\n \u003cli\u003eAdaptations to the model during the implementation stage contributed to its success as problems were identified and solved in real-time, for example, streamlining process for acute ward nurses to reduce time burden\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRLM Domain 4. Outcomes\u003c/strong\u003e - evidence which captured the successes of the innovation pilot and potential effect modifiers to the model are noted. Outcomes are described under subheadings as follows:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eImplementation outcomes:\u0026nbsp;the virtual VMO model was found to be appropriate to address the identified need and to provide an efficient and effective solution; the model is replicable and scalable to other rural contexts.\u003c/li\u003e\n \u003cli\u003eSystem outcomes: a tested virtual inpatient model of care to provide rural health services with medical practitioner coverage on weekends and to provide relief to the GP-VMO workforce. A replicable package is available for other rural health services to implement the model, noting the lessons from the evaluation of the pilot. \u003cem\u003ePotential effect modifiers:\u0026nbsp;\u003c/em\u003erural GP workforce shortages, attraction and retention remaining critical issues, the model being complementary and not a replacement for the rural GP workforce.\u003c/li\u003e\n \u003cli\u003eService outcomes: a viable virtual VMO model which contributes to the rural health service\u0026rsquo;s strategic plan and goals, for example\u0026nbsp;to provide local, personalised and accessible care close to home. The model continues at the health service.\u003c/li\u003e\n \u003cli\u003eStaff outcomes: reported acceptance of the virtual model; evidence of increased professional learning for acute ward nurses when interreacting with the telemedicine provider\u0026rsquo;s medical practitioners; satisfaction amongst staff with the quality of care provided.\u003c/li\u003e\n \u003cli\u003ePatient outcomes: patient reported acceptance and satisfaction with the telemedicine model. \u003cem\u003ePotential effect modifiers:\u003c/em\u003e patients value their local GP and were concerned about loss of their local GPs.\u003c/li\u003e\n \u003cli\u003eClinical outcomes: patient reported improvement to their clinical situation, for example medication change which resulted in improvement to a leg wound; nurse reported improved clinical outcomes due to timeliness of access to care (weekend/afterhours coverage).\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Image","content":"\u003cp\u003eImage 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"rural healthcare, telemedicine innovation, implementation frameworks, virtual inpatient clinical services, medical workforce","lastPublishedDoi":"10.21203/rs.3.rs-6166035/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6166035/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe connections between preparation and implementation factors when introducing virtual models of care in rural inpatient settings are critical for success but remain unexplored. This evaluative study investigated the introduction of a virtual medical officer innovation in three acute wards of a rural health service in Victoria, Australia. To present novel insights, we examined the results using constructs from two implementation frameworks, the Exploration Preparation, Implementation, Sustainment (EPIS), and the Consolidated Framework Implementation Research (CFIR). To synthesise findings, the Implementation Research Logic Model (IRLM) was utilised.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe evaluation was process-outcome orientated, undertaken from December 2022 to June 2023, deemed the innovation\u0026rsquo;s pilot phase. A mixed methods approach was employed, incorporating a review of documents pertaining to the model, an electronic survey specific to nurses at two time points (preparation and implementation), and semi-structured interviews targeting, two groups; Group one, health system stakeholders (nurses, doctors, managers and virtual medical officers) and Group two, patients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe document review emphasised the important pre-implementation or exploration factors which were an interdependent platform for subsequent implementation phases, for example having a clear understanding of determinants such as the rural context, the problem and need. Interview findings (n\u0026thinsp;=\u0026thinsp;77), involving Group one (n\u0026thinsp;=\u0026thinsp;39); and Group two (n\u0026thinsp;=\u0026thinsp;38), were categorised into three overarching themes; Facilitators of the telemedicine model, Barriers to the telemedicine model, and Sustaining telemedicine innovation gains for the future of rural healthcare. Critical preparation factors identified were the relational culture of collaboration and partnership during innovation design negotiation, and the importance of organisational and individual leadership. Implementation factors highlighted the effectiveness of the project management approach, and responsive adaptation, such as active feedback loops leading to model adjustment to increase acute ward routine efficiency.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study has policy implications for the development of rural medical workforce strategies and the planning of a rural digital healthcare strategy. Our identification of determinants contributing to implementation success, and use of the Implementation Research Logic Model to illustrate connections, would aid decision makers when designing, introducing and adapting rural healthcare innovations to be relevant to context.\u003c/p\u003e","manuscriptTitle":"Preparation and implementation factors in rural healthcare innovation: a mixed methods investigation of a virtual medical officer model of inpatient care in Australia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 07:00:24","doi":"10.21203/rs.3.rs-6166035/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2025-06-11T17:20:09+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-04-01T14:23:11+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-01T14:21:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-12T20:21:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2025-03-11T16:51:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"008421c0-380c-46f9-8ffe-1167257bdbcb","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-19T22:15:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 07:00:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6166035","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6166035","identity":"rs-6166035","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}