Virtual health – evaluating in a shifting landscape

Earlier this year, Rachael Butler and I completed a series of rapid reviews for Waikato District Health Board, looking at current thinking in virtual health – where advances in technology enable remote forms of healthcare delivery. Some anticipate that it will comprise a substantial proportion, if not the majority, of patient interactions in the future.

What is virtual health?

Discussion about telehealth and telemedicine approaches are often used interchangeably with virtual health. In the work we developed with our partners, virtual health was proposed as an evolutionary step beyond telehealth and digital health approaches, which is patient-centred and engages people as partners with clinicians in maintaining and improving their health.

Reported benefits of virtual health include improved access to healthcare and health and wellness education, increased patient engagement and satisfaction, a reduction in direct and indirect costs, and improved health outcomes. Virtual health programmes have also been linked to positive outcomes for health providers, including improved operational efficiencies, a reduction in costs, alleviation of staff/provider shortages, and access to a pool of clinical resources.

There’s always a 'but'

We found that virtual health initiatives have the potential to deliver patient-centric care, create more collaborative ways of working and make health systems more efficient. But when you’re talking about potential, there’s always a but. And with virtual health, clinical uptake is often a key challenge, along with the readiness of organisations to implement technology, and the suitability of technology for the purposes intended. Furthermore, users of virtual health systems – both clinicians and consumer/patients – should be involved in developing new initiatives, be adequately trained, and feel confident that the technology is safe, offers clear benefits, and is easy to use.

A copy of the synthesised reviews can be accessed here, where the above discussion is dealt with in substantially more detail.

Evaluating virtual health

When we presented on these findings at the 2018 ANZEA Conference, I offered some reflections about evaluating these types of approaches, drawing on the writing of Trisha Greenhalgh, one of the leading thinkers in this space. Trisha Greenhalgh’s 2018 book, How to implement evidence-based healthcare, is an excellent starting point.


The landscape of virtual health technologies is one that is constantly being iterated and refined. Maintaining a stable, unchanging intervention is really challenging in the context of apps that are being updated on our phones on a near-daily basis. So evaluations that are based on a linear assumption of stability and predictability may well be flawed from the outset. Evaluating technological interventions need to be seen in the light of something that is iterative, recursive and a long-term process – a developmental process.


The six worlds

Greenhalgh writes of six ‘worlds’ with significantly different stakeholder perspectives and expectations of technology interventions; each with their own evaluation needs:

  • Political, where technology is a vehicle for delivering policy, improving efficiency and providing measurable benefits to patients
  • Clinical, where technology is a tool to support professional practice and improve quality of care
  • Personal (patient/carer), where technology supports the individual’s personal health and wellbeing
  • Technical, where the focus is on design and as a software development project
  • Commercial, as a way of delivering return on investment
  • Legal/regulatory, in terms of information governance.

Getting comfortable with the complex

Greenhalgh and colleagues are particularly critical of systematic reviews of randomised control trials that overly simplify both the technological interventions and the outcomes they expect, and which often fall back on needing more research to gain a greater effect size. Instead, she argues for greater use of mixed methods and ethnographic research that embrace both context and complexity, to better understand the pathways and processes through which technological interventions fail or succeed, and use real-world experience to make sense of multiple and imperfect data sources.

In short, virtual health approaches are here to stay, and they will continually be refined and adapted to better meet the needs of people – many of which will fail to do so. Understanding technological value and impact needs to embrace the complexity of the different worlds of technology, and work similarly developmentally and iteratively as their real-life experience unfolds.


The review that this post is based on was commissioned by Waikato District Health Board over late 2017 and early 2018. The Smarthealth and Healthtap initiatives were outside the scope of our review.