Virtual hospitals: The future of the healthcare system? An expert consensus

Identification of the specific context and reference literature

The study started with a literature review using the Scopus and Pubmed platforms. ³⁷ The Scopus search yielded thousands of contributions. Specifically, 7132 results were obtained, of which 4923 were attributable to the field ‘Medicine’, 1265 to ‘Computer Science’, and 1075 to ‘Engineering’ . However, it was impossible to proceed with a structured, bibliometric, or systematic review, as papers addressing the topic as a whole were absent. In fact, numerous contributions were classified within multiple and varied topics, including ‘Health professions’, ‘Social Sciences’, ‘Nursing’, ‘Biochemistry’ and ‘Mathematics’. The reading of the 92 abstracts of the papers labelled ‘Business Management and Accounting’ led to the identification of some unique (but often marginal) and varied aspects of the problem, including telemedicine, ³⁸ sustainability aspects, ³⁹ logistics management, ⁴⁰ and issues related to the Covid-19 pandemic.^41,42 However, almost all the abstracts were out of context concerning the main topic under investigation, namely the characteristics of a virtual hospital.

Therefore, an analysis of grey literature was also carried out, including both relevant reporting documents on the subject as well as ministerial acts and significant cases of international trials of particular interest for the present study, such as the Mercy Virtual Care Centre in the United States, the Abu Dhabi Health Services Company (SEHA), and the Fiona Stanley Hospital in Australia.

Given that the Mercy Hospital is the only facility that can be defined as a Virtual Hospital, since it has no beds and patients are not physically hosted inside the centre, we decided to use it as a key case study for starting the expert consensus.

 Table 1 below shows the main services, technologies and benefits offered by the Mercy Virtual Care Center, as well as the evaluation of some of their programs.

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Table 1.

Mercy virtual care center, St. Louis, USA – facts and services.

Description of the experience and results

The Mercy Virtual Care Center in St Louis, Missouri, operational since 2015, was the world's first telemedicine centre and offers virtual patient care in the United States. 43 The centre houses a large team of healthcare professionals and provides primary telemedicine services using highly sensitive two-way cameras, IoT, care navigation technology and electronic medical records, allowing patients to be monitored without being physically with them. Specifically, a doctor keeps an eye on several monitors at the same time and checks patients at home to make sure they are taking their medication correctly and assesses their vital signs with biometric sensors and a ‘virtual’ care kit that may include an iPad and sensors to be used at home once they are discharged from hospital. The centre, therefore, was created with the aim of serving and providing ongoing care to the community as a whole, overcoming traditional cultural, political and/or geographic barriers and harnessing technology to provide a model that remains true to the doctor-patient relationship, but allows for greater clinical efficiency and effectiveness.

Services, technologies and benefits offered

1 eICU (electronic Intensive Care Unit), which connects 30 ICUs (Intensive Care Units) in seven states, Remote surgery using robotics Telestroke, radiology and pathology services Care management On-call nursing E-pharmacy Primary care and home health, Management of a larger number of patients and greater disease severity Use of big data strategies Greater accessibility, efficiency, effectiveness, equity and security Continuous monitoring of chronic diseases Improved efficiency for staff Remote clinical collaboration Improved efficiency for staff Patient-centred Rationalisation of specialist care and care delivery

The center is also designed to be a training venue for new staff and a research incubator for new care models.

Evaluation of Mercy's programs

50% reduction in preventable readmissions; 35% fewer hospital days; 60% fewer septic shocks deaths 44 Increase in the number of patients followed without increasing staff members, from around 2300 patients to the current 4,600 45 Increase in virtual visits during the pandemic time: from 10,000 in 2019 to 800,000 + from March 2020 to the end of 2021 46 Reduction in the total operating expense per patient per month (pppm) from more than $750 pppm to less than $300; 50% reduction in inpatient utilization 45 98% patient satisfaction score 45 Ranked among the 25 largest U.S. health systems 46 Collaboration with other primary healthcare institutions (for instance, Penn State Health) 47 Awarded with grants to extend the services (for instance, a recent $2.2 million grant from the Federal Communications Commission to expand and upgrade telehealth services for patients across Arkansas, Missouri and Oklahoma) 46 Winner of the 2017 AIA/AAH Healthcare Design Award. 48

Creation of the panel for expert consensus

The expert consensus has been based on the EFTE (estimate, feedback, talk, estimate) approach ³⁶ also known as ‘mini Delphi’, which has already been used in other studies in the healthcare sector.^25,49

The Expert consensus is a research method that must be rigorously managed to lead to scientifically valid results. The literature recommends, in particular, the selection of experts characterised by diversity and variety in expertise and independence in considerations and choices. ⁵⁰ In order to meet these criteria, the experts were selected based on their specific expertise. More specifically, the aim was to gather people with a multidisciplinary background, coming from strategic innovation, public and health policies, social statistics, health and corporate management, medicine and surgery, sociology, psychology, and sustainability. Fourteen experts coming from the Ca’ Foscari University of Venice, the Veneto regional leadership, and two prominent medical scholars from Piedmont (University of Turin) and Lombardy (University of Pavia) were involved in the analysis, to give their opinion about the subject of potential benefits and hurdles in implementing the Virtual Hospital model, in the Italian social health system.

Data collection and analysis

The analysis was conducted in May 2022, following the path described below:

The Ca’Foscari group carried out a preliminary analysis of the topic by analysing the professional and ‘grey’ literature (reports published by consultancy firms, international companies and organisations, websites of leading health and technology institutions, …). In addition, one international case study was considered to define the key points for the subsequent comparison with the multidisciplinary team;

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Figure 1.

The flow followed (EFTE process).

Virtual hospital features and target audience

The panel was asked to highlight the differences between the concepts of telemedicine and digitisation on the one hand (vital but not exhaustive aspects of the Virtual Hospital model) and the concept of Virtual Hospital on the other hand.

It emerged from the debate that telemedicine is intended as the provision of healthcare services through the use of innovative technologies, such as Information and Communication Technologies (ICT), in situations where the health professional and the patient (or two professionals) are not in the same location. ⁵⁶ However, this approach involves a one-off intervention, which is activated following a patient's request.

In contrast, the Virtual Hospital offers continuous assistance to the patient, carried out remotely, similar to that provided in a physical hospital. The center, in fact, does not have any beds. Still, instead, it holds only the healthcare professionals who are able to monitor the patients remotely and offer them virtual care. The success of such an initiative can only be achieved through the development of an adequate degree of interoperability between both different devices used and the information systems. ⁵⁷

Since these virtual hospital care models aim to provide the same level of care that would be provided in hospitals, they will operate in an interconnected manner while preserving a certain degree of autonomy. In this sense, the discussion group questioned which services should be provided by these facilities and which segment of the population is most interested in the development of such a model.

With reference to the first question, what emerged as pre-eminent services were those aimed at providing patients with continuous, quality care 24 h a day, 7 days a week, while allowing the patient to remain at home or at any other remote destination. This implies the need to provide direct and rehabilitative treatments through integrated multidisciplinary approaches and the development of individualised care plans involving the direct involvement of the patient and the family or caregiver in-home treatment and care. ²⁴ In addition, the collection of data allows the center's physicians not only the preventive identification of patients at high risk of hospitalisation but also to access the patient's history and monitor his or her vital signs. Moreover, it permits access to the patient's medical devices, such as a glucometer, pulse oximeter, and blood pressure measuring instruments, as well as to access laboratory reports and assess readiness for discharge based on predictive risk reduction. ⁵⁸ Finally, the use of video-conferencing or video consultations, usually delivered by telemonitoring, allows for remote visits and proves to be an effective way to increase access to screening and care, conduct medical consultations and supervise treatment and rehabilitation. ²⁴ This allows, on the one hand, better quality and faster service provision and, on the other hand, a significant reduction in the time taken for visits and, consequently, an equally significant reduction in costs compared to hospital-based visits.

Regarding the second question, the Virtual Hospital model and its services seem to be more efficient if it is aimed at a specific target group of patients, i.e., those who are in follow-up. These include, for example, frail, elderly patients and/or those who have one or more chronic conditions, such as heart disease, stroke, diabetes, some chronic respiratory disorders, etc.

Advantages

The panel questioned the advantages deriving from using a Virtual Hospital model on the main stakeholders, namely patients, operators, health facilities involved, and public bodies / national health systems. Table 2 below illustrates the benefits as defined by the literature and emerged during the multidisciplinary discussion.

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Table 2.

Impact and potential value of a Virtual Hospital model on patients, operators, health facilities involved, and public bodies / national health systems.

Value for patients

Continuous monitoring of chronic diseases Possibility of being assisted from any location and obtaining specialised services or advice Improved access and equity to healthcare Saving time and money Timely diagnosis and accurate interventions by refining the individualised care plan and the therapeutic profile Increased predictivity Early identification and analysis of diseases Building trust in the patient-health professional relationship Improvement of the patient's care experience Reduction in aggravation factors and mortality Less chance of being exposed to pathogens (e.g., COVID-19) Continuous care by a multidisciplinary team (team care) Coordination of care delivery with an Evidence-Based Medicine approach Increased independence and self-management verified by healthcare professionals and not self-referral Improved communication and relationship between patients and healthcare practitioners Improved overall experience and outcome Substantial improvement in quality of life

Value for operators and health facilities

Possibility of taking care of more patients Reduction of waiting lists Saving resources and increasing sustainability Reduction in the number of emergency room admissions, hospital (re)admissions, and healthcare costs Increased efficacy and efficiency of care Improved work-life balance of operators with diminished risk of burn-out Improved relationships and trust with patients resulting in fewer physical consultations and hospital readmissions Automation of repetitive activities and hospital back-office and auxiliary services Improved triage and organisational and decision-making procedures Reduction of errors

Value for public bodies / national health systems

Improvement in the ability to respond to health and social needs Progress in the territorial management of chronicity at home Improved health data and information sharing Better allocation of resources and budgets Increase in the value of social and health services offered and improvement of pathology indicators Improvement of overall population health with a view to proximity medicine

The panel observed that virtual hospitals are able to offer numerous advantages due to their unique and high-tech environment, both for patients and healthcare providers, as well as for the public authority itself. Indeed, they exploit technology to provide a model that remains faithful to the doctor-patient relationship but allows for greater clinical efficiency and effectiveness and provides access to care for all. ²⁸

With reference to the former, i.e., the patients, it is observed that this model can be defined as “patient-centric,” due to the continuous assistance of a team (team care), ⁵⁹ the coordination of care delivery, and the utilization of the entire set of skills available within the health care system continuum, thus providing more patient-centred care, which is able to acquire greater independence and self-management. ²⁹ Indeed, such a system provides the appropriate tools to help people understand, monitor, and manage their health conditions with greater autonomy, involvement, and responsibility. Furthermore, digital health monitoring enables patient empowerment and stimulates co-production dynamics,^60–62 improved communication and relationship between patients and health professionals, more timely diagnoses and accurate interventions, and a better overall experience and outcomes for the patient. ¹¹ The use of big data, in addition, would allow the development of treatments that are, to a greater extent, based on predictive analytics, thus intervening in a preventive and timely manner and developing solutions that are more personalised and participatory but also more efficient and effective. ²⁸ The Virtual Hospital model, therefore, thanks to its high level of digitalisation, permits early identification and analysis of diseases, enabling proactive intervention (defined as initiative medicine) and thus improving understanding of disease progression, resulting in a significant reduction in mortality and a substantial improvement in quality of life. Moreover, in virtual hospitals, the number of patients who can be cared for remotely increases more than in physical hospitals, and this is because patients can be cared for from anywhere (their own home, residences for the elderly, nursing homes or hospices or other care facilities), without the need for outpatient clinics or hospitals.^56,63 This frequent mobility, especially for the elderly with chronic illnesses, has undoubtedly been a critical issue that elevated the risk factors of Covid-19 infection and generated outbreaks in care environments and hospitals. Through the Virtual Hospital, one can thus obtain some of the specialized services of hub hospitals without having to physically arrive there, saving time and money and remaining in a more familiar, welcoming and safe environment with less chance of being exposed to pathogens or, on the contrary, spreading them. What is more, this model ensures better accessibility and equity of care and healthcare by providing access to services not otherwise available (thus reducing inequalities in access to healthcare services) and offers greater efficiency, especially with regard to monitoring elderly or chronically ill patients who require follow-up care.^34,64 Moreover, teleconsultation allows the involvement of expert or top clinical professionals specialised in some diseases besides those already caring for the patient.

In those contexts where telemedicine and digital monitoring solutions have been implemented, they have been found to establish better relationships and trust with patients while reducing physical consultations and hospital readmissions. ⁶⁵ Moreover, the use of virtual solutions and robotics can lead to a downsizing of the administrative workload, potentially reducing the risk of burn-out, increasing staff efficiency and reliability and optimising the time of the operators (workflow efficiency) by automating repetitive tasks and hospital back-office and auxiliary service.^2,54 In fact, by simply touching a screen, nurses and other medical staff can call up robots for specific tasks, such as the supply of drugs, transporting blood samples, collecting diagnostic results and scheduled delivery of laundry and food, either as a pre-programmed task or as a real-time request. ² Furthermore, within virtual hospitals, it may be expected an improvement in triage/intake, which can be performed remotely via a video conference with a nurse and/or general practitioner, thus improving access to healthcare and reducing the costs of emergency room visits.^2,53

Virtual hospitals allow reducing healthcare costs by decreasing the number of hospital (re)admissions, saving expensive resources such as hospital stays while ensuring the most appropriate care while the patient is at home – see the section Description of the experience and results of Table 1.^28,66 In fact, health system managers are often faced with issues related to insufficient budgets, increasing financial pressures and citizens’ expectations. The use of e-health can play an essential role in reducing these pressures by making healthcare institutions more productive and less wasteful through lower service costs, better prevention, de-hospitalisation and optimisation of the hospital network. ⁶⁶ It should be borne in mind that the organisation of transport, especially for fragile patients involving the use of equipped vehicles and personnel, is one of the most complex and costly elements to manage. ⁶⁷ At the same time, information technology procedures would allow health authorities to optimise processes by speeding up organisational procedures, increasing efficiency and effectiveness in the management of work phases, distributing responsibilities and reducing errors and deaths, ⁶⁸ and this is thanks to the continuous and multilevel availability of patient data. Overall, therefore, the Virtual Hospital model is able, on the one hand, to identify and support the well-being needs of the operators, improving the job satisfaction of individual staff members and thus enabling them to have a better work-life balance. ⁴² Moreover, such a new model is likely able to promote considerable savings in human and financial capital and an increase in sustainability, both from an environmental and economic point of view.

Finally, from the public bodies / national health systems perspective, governments, by using this model of care, can allocate resources more appropriately, increasing the value of social and health services and improving the overall health of the population. ⁶⁸ It is for this reason that they are increasingly adapting to and facilitating digital transformation in the health sector. Therefore, in order to achieve healthcare systems that are increasingly focused on creating and maximising value (pay for value), governments must play an active role in creating a guiding framework for the healthcare sector to overcome these challenges and support change in the ecosystem, bringing value not only to patients but to society at large. ⁶⁸

Barriers

The process of implementing the Virtual Hospital model inevitably encounters several barriers, ⁶⁹ which can be mainly attributed to 4 macro areas, such as: infrastructure and technology, digital skills, organisation and culture, as shown in Table 3 below.

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Table 3.

Major barriers to implementing the Virtual Hospital model by macro-area.

Infrastructures and Technologies

Limited capacity for data collection and digitisation Low degree of interoperability between devices and information systems Lack of shared and interoperable standards for data digitisation Lack of integrated repositories for data collection and management (cloud and privacy) Lack of a homogeneous and robust information technology (IT) structure across the territory Poor uptake of the Electronic Health Record (EHR)

Digital competencies

Lack of training in the proper use of technology Limited dissemination of a digital culture Lack of experienced professionals in digital health, robotics and automation

Organization

Resistance to change and technological innovation Complexity in the coordination of health professionals with different skills Complex territorial organization and interaction with social needs Need to redesign traditional models of care on performance logic and DRGs Need to redefine career paths and staff roles Limited application to patients in follow-up Absence of common national goals Absence of a specific regulatory framework

Culture

Low digital literacy Limited cooperation among actors Low trust placed on digital health services by clinicians and patients Breakdown of traditional value models

The use of state-of-the-art technology and the uniform and robust presence of IT infrastructure (Wi-Fi, fibre optics, broadband, data center, etc.) throughout the territory, are essential for the proper functioning of the system, which relies mainly on the collection, processing, and exchange of large amounts of data. These need to be collected and digitised, following precise shared and interoperable standards that ensure their quality and interchangeability among different operators, a challenge that can only be addressed through cooperation among multiple actors at local and national levels. ⁵⁹ The lack of shared standards, on the contrary, hinders the homogeneous distribution of data between different areas, consequently making it impossible to compare medical, health and epidemiological data, as well as preventing the proper functioning of algorithms typical of artificial intelligence. ⁷⁰

Nowadays, at the national level, it emerges a quantitative and qualitative deficiency of collected and digitised data, as well as low interoperability between existing devices and operating systems, the cause of which is mainly identified in the delay of the sector's digitisation due to the low diffusion of basic tools such as electronic medical records. ⁷¹ The management and exchange of data at the digital level may also raise privacy concerns, for which reason it is necessary to develop a specific regulatory framework that allows the clear identification of the data owner and the definition of specific conditions under which a secure and ethical use of the data can be ensured.^25,27,72

Investments

For the implementation of the system, a further aspect is to be considered, namely the needed investments. This latter, on the one hand, shall be directed to the purchase of tangible assets, such as technological tools and cutting-edge information systems, and on the other hand to the development of intangible assets such as digital skills for the use and the fruition of digital services, as shown in Table 4 below.

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Table 4.

Investment needed in tangible and intangible assets to implement the virtual hospital model.

Tangible Assets

Apps for patient and virtual hospital care team – needed by the former to make virtual appointments and send messages to doctors/nurses, giving the latter the ability to consult on symptoms, monitor health status (e.g., vitals and symptoms) as well as medication intake, view treatment plans, request medication refills, etc. The apps can also be used by caregivers (e.g., a relative) to better coordinate care. Video streaming server for real-time audiovisual communication between patients and the virtual hospital care team. Cloud-based data storage and processing module for storing PHI, consultation records, etc., and analysing patient information (e.g., device-generated data, treatment plans). Administration web panel (for virtual hospital administrators, etc.) - to manage user access to the virtual hospital software, view patient list, etc. Smart medical devices for patients – to provide the virtual hospital care team with real-time data on vital parameters, medication intake, etc., for disease monitoring. Electronic health record and digitised EHR/EMR medical record – to provide instant access to the patient's medical history, chronic conditions, allergies, contact information for the virtual hospital care team, etc. Practice management system – to facilitate patient access to health specialists’ schedules, automate patient billing data entry into the system, etc. Medical imaging software and laboratory information system – to enable an instant view of the patient's x-rays, CT scans, etc., and laboratory test results to enable the care team to decide on treatment adjustment, readmission of the patient to the hospital, etc.

Intangible Assets

Development of a new multidisciplinary model of care: Recruitment of new specialised Human Resources for remote clinical collaboration. Development of new technical, professional, digital and managerial skills of health system staff Specific university training on e-Health Competencies, such as the use of electronic health records, digital documents, secure clinical data sharing, decision support systems, secure information storage, electronic prescription management and digital tools for patient engagement Training and continuous competence development for health professionals (life-long learning) related to basic digital competencies (digital literacy) related to the use of digital tools or applications such as chats, video calls, social networks, chatbots and voice assistants as well as specific e-health competencies, which refer to the use of the above-mentioned tools Training of patients and caregivers Total sharing, not only of scientific and technological knowledge but also of strategic and governance goals (One Health – One Governance) Definition of new clinical procedures and measurement methodologies

Currently, digital literacy is scarcely widespread. Still, it proves to be crucial among clinicians and patients, for the first group to use new tools to deliver care services, and for the second one to take an active part in the healthcare process, given the fact that patients may be located in remote destinations and not in a central facility. ⁸ This last aspect is crucial because, if poorly implemented, it can limit access to health services to that part of the population that is more fragile. The two categories which are most at risk are the elderly, ⁶⁷ as they constitute one of the largest groups targeted by the healthcare system, and the low-income citizens who, due to economic and cultural constraints or because of structural reasons, do not have the necessary tools to benefit from the services provided by this model.

Moreover, the implementation of the model, from an operational point of view, requires putting in place several organizational changes, both internally and externally, such as the redesigning of care models, career paths and staff roles to efficiently provide care to patients. ⁵³

Finally, to successfully implement this model is crucial to encourage the adoption, among clinicians and patients, of a totally new digital mindset. A great percentage of CEOs (chief executive officers) and CIOs (chief information officers) of healthcare organizations still consider today virtual-health and telehealth as mere “second class” options to adopt when the traditional model is not available, ⁵³ while many patients do not trust digital health services, which are considered to be of low quality and more prone to medical errors.

Adopting new technological solutions will also lead to creating new relational and value models, where delicate aspects concerning the personal identity and the sense of belonging to a professional community are called into question. ⁶⁸ One of the risks, for example, is that the introduction of artificial intelligence can be perceived as a de-qualification and delegitimization by healthcare personnel, ²⁵ while old patients, who are not used to technology, may not accept the new digital model of service delivery. ⁵³