The results of this study highlight that digital transformation in healthcare is a pervasive technological shift presenting substantial challenges for rural and regional communities [30]. Healthcare professionals reported micro, meso, and macro-level challenges intricately linked to digital determinants of health—factors such as digital literacy, internet connectivity, device affordability, and the availability of digital health tools and resources [31, 32]. These factors highlight potential disparities in digital health access and outcomes between rural and metropolitan areas, particularly for patients with low digital literacy and language barriers. The lack of resources to support patients with low digital literacy and language barriers underscores the need for tailored approaches to improve RPM implementation. Healthcare staff also discussed different levels of skills and training in RPM, with participants stressing the need for specific training and the recognition of the special skills required for RPM tasks, particularly in rural settings where it may be difficult to attract and retain staff [1]. These broad challenges associated with digital health in rural areas, consistent with previous studies, have been well-illuminated in the literature [1, 2, 16, 19,20,21, 33].
The healthcare professionals in this study provided several strategies that may mitigate the unique barriers facing RPM implementation in rural and regional Australia, that fell under three themes: (1) the necessity for effective strategies to ensure everyone can access and benefit from RPM regardless of their location, (2) the critical need to bridge the infrastructure and technological divide by investing in IT infrastructure that may elevate rural areas to the same standards as metropolitan regions, and (3) the urgent need for sustainable and targeted funding models to ensure the equal distribution of resources and support the long-term viability of RPM initiatives. These results suggest that there may not be a single, universally applicable strategy to address these challenges; instead, the implementation of remote patient monitoring (RPM) in rural and regional settings may require a multifaceted set of strategic actions [34]. The three themes are discussed in more detail below.
Accessible RPM
Acceptability
Contrary to findings from the COVID-19 era, [16, 18,19,20,21], our qualitative research, encompassing a broad spectrum of RPM services, suggest that RPM may not be universally suitable across all clinical scenarios. Importantly, the findings of this study bring to focus a nuanced perspective among healthcare providers in rural and regional settings: while they use and acknowledge the potential benefits of RPM, they may prefer face-to-face interactions with specific patient groups and under certain medical conditions. For instance, participants mentioned a reluctance toward digital modalities in areas like Midwifery (theme 2), where clinicians preferred more traditional, in-person consultations, reflecting the value placed on personal interaction in rural healthcare contexts. Conversely, in the post-partum period, there was a marked preference among new mothers for RPM, welcoming the use of tools such as questionnaires for data collection if these could replace or shorten the duration of clinic visits. Consistent with findings from other research [20], clinicians perceived targeted data collection for RPM as practical and effective for certain conditions like congestive heart failure, diabetes, asthma, weight management, and post-surgery recovery. This variability suggests a need for RPM programs to be flexible and tailored, considering factors such as the complexity and sensitivity of the health condition and the need for physical examinations.
An important consideration is the distinction between initial digital interactions and established patient relationships [15]. In rural settings, where personal interaction is reportedly highly valued, initial face-to-face consultations may be crucial for building the necessary trust and rapport [1]. This foundation can make subsequent digital interactions more acceptable and effective. Therefore, hybrid models, which combine initial in-person visits with digital follow-ups, could offer a more effective approach for RPM programs in rural areas. This distinct shift has been emphasized following the onset of the COVID-19 outbreak [15]. Nevertheless, emerging research has raised concerns about the potential mental health risks associated with digital services; suggesting that these services might discourage physical activity since patients are not incentivised to leave their homes for appointments, which could negatively impact their overall well-being [22]. Notwithstanding, these dynamics may warrant further investigations to ensure the efficacy of RPM programs. Additionally, implementing an RPM assessment or checklist to identify suitable patients could enhance the effectiveness and efficiency of these programs. By systematically evaluating patient suitability, healthcare providers may ensure that RPM is appropriately matched to individual needs and conditions, improving overall outcomes [35].
Affordability
Ensuring equitable access to RPM technologies requires addressing key barriers such as affordability, particularly for vulnerable populations in rural areas [36, 37]. Participants also pointed out that certain patient groups, like older adults, might hesitate to use RPM due to the costs associated with data plans or internet services. This aligns with findings from a telehealth study, which emphasized how costs significantly influence consumer decisions [11]. Participants expressed a preference for cost-effective RPM solutions, as higher out-of-pocket expenses remain a significant barrier in rural areas. This indicates that RPM initiatives that reduce or eliminate patient costs are likely to see higher acceptance and use among the intended populations. Importantly, existing research has shown that older people are not necessarily less likely to use RPM. Studies indicate that with adequate support and resources, older adults can effectively engage with RPM technologies [38]. Findings highlight the importance of integrating telemonitoring into care models to support patients with complex conditions, regardless of age [38]. This suggests that barriers to RPM use among older adults can be mitigated through supportive measures, such as providing tools and training for self-management [38]. Nevertheless, it is essential to further investigate these concerns, indicating a need for targeted discussions with consumers such as older people living in rural and regional areas to better understand their specific barriers and preferences, particularly related to affordability [15, 38]. Additionally, it could be worth considering the broader needs of end-users, including both patients and healthcare providers, when designing inclusive and effective RPM programs, ensuring the technology is also evidence-based [15].
IT infrastructure
The findings of this study suggest that rural and regional areas could significantly benefit from enhanced internal information technology (IT) support that matches the comprehensive systems found in metropolitan hospitals [37]. Strengthening these capabilities is vital to avoid fragmented services, delays in addressing urgent IT issues, and disruptions in RPM system operations. Achieving this enhancement, however, is complicated by varying levels of dedicated IT support in rural hospitals. In certain cases, coordination with larger referral centres becomes difficult, resulting in data silos and communication breakdowns [39]. This means that essential patient information is often trapped within isolated systems and not readily accessible to other hospitals that need it, leading to inefficiencies and potential errors in patient care. Additionally, these isolated systems raise significant concerns about data privacy and security [39]. When hospitals lack dedicated internal IT teams, they may rely on external or outsourced IT services, which may not prioritize patient confidentiality to the same extent as internal teams. This reliance increases the risk of data breaches and unauthorized access, making it crucial to strengthen internal IT capabilities to safeguard patient data effectively [39]. These organizational issues are especially evident in rural and regional settings, where limited local resources and the logistical challenges of maintaining advanced IT infrastructure in remote locations exacerbate the problem [40].
Moreover, systemic barriers such as inadequate infrastructure and fragmented governance further complicate efforts to implement reliable IT systems. Evidence from other sectors, including agriculture, banking, and education, highlights similar challenges, where systemic inefficiencies and delays hinder operational delivery and service effectiveness [37]. For example, insufficient IT support in rural banking branches can lead to service delays and increased vulnerability to security breaches [41]. In education, the digital divide between urban and rural schools exacerbates educational inequalities, affecting students’ access to quality learning resources and support [41]. These cross-sectoral challenges suggest the need for a cohesive, cross-sectoral strategy to address infrastructural deficiencies in rural and regional areas [41, 42]. Such a strategy could enhance healthcare delivery through improved RPM systems and bolster overall community development by integrating solutions across various sectors.
Evidence on health investments in Australia highlight significant disparities in per-capita health spending between urban and non-urban citizens, with a shortfall of $848.02 per person in 2020–21, amounting to a total shortfall of $6.55 billion [42]. The inequitable investment in IT infrastructure means these areas often lack the necessary foundation to support innovative digital solutions. Participants discussed challenges related to fragmented IT systems and limited alignment with local needs. Moreover, many RPM studies reported in the literature are conducted within metropolitan healthcare settings [16, 17] and globally [18,19,20,21]. While these systems may reflect the priorities and resources characteristic of urban healthcare environments, their applicability to rural and regional contexts remains uncertain [43]. It stands to reason that interventions studied or tested within metropolitan settings may not fully account for the unique challenges faced by non-urban populations [15]. Designing these interventions with rural and regional contexts in mind from the outset, rather than simply adapting metropolitan solutions, may ensure they are better suited to local needs [15, 44]. These discrepancies suggest that tailored solutions and equitable investment could play a crucial role in improving healthcare outcomes in rural settings.
Healthcare funding
A significant barrier identified was the misalignment of funding models between metropolitan and regional areas. Participants noted that the funding periods are typically too short to support the long-term investments in workforce and facilities necessary for creating sustainable RPM programs. This lack of sustained investment could also undermine efforts to provide the certainty required to attract and retain clinicians in non-urban areas [45]. Moreover, current Australian funding models for metropolitan hospital is through activity-based funding and fee-for-service funding, with block funding common in rural and regional setting, making it challenging to get a clear picture of the disparity in health expenditure [42]. Reports also show rural Australians have a poorer health status, and even before accounting for the increased cost of health service, receive significantly less funding per capita than their urban counterparts [42]. In theory, RPM programs funded through block grants can achieve budget neutrality or even cost-savings by preventing emergent hospitalizations from exacerbation of chronic disease, which often involve lengthy stays whose costs exceed the standard reimbursement [22, 46]. However, in practice, small hospitals may often hesitate to invest in RPM for chronic disease management, especially during periods of budget cuts, due to the uncertainty of outcomes for small programs. Furthermore, RPM programs that are cost-effective in terms of patient outcomes and quality of life might not meet the threshold for budget neutrality or cost savings [22].
Nevertheless, in metropolitan areas, which operate on activity-based funding, RPM programs are often not classified as National Weighted Activity Units (NWAUs)—a measure used to allocate funding based on the complexity and type of hospital activity—potentially preventing direct reimbursement for remote monitoring activities [22, 35]. This classification issue in metropolitan areas highlights the broader systemic challenges faced by both urban and rural health services under the current funding models [22]. Although federal and state governments appear to recognize these challenges and have invested in programs to address the health issues in rural Australia, these efforts may not have fully overcome the disparity in health outcomes [42]. The current pattern of health service use suggests a missed opportunity for early intervention and preventative healthcare [42]. Additionally, current funding models and service delivery arrangements create significant barriers to workforce recruitment and retention, further exacerbating the funding shortfall [47].
To effectively address this inequity in healthcare and health outcomes, the specific barriers to delivery and the shortcomings of the current approach need to be acknowledged [1]. A one-size-fits-all approach to funding arrangements may not be effective in addressing the complex challenges faced by non-urban communities [12, 42]. Tailored funding models that address the specific needs and challenges of rural Australia may prove promising [22, 42]. Additionally, alternative mechanisms for RPM reimbursement, such as bundled payments (payment for well-defined care pathways spanning multiple care settings over long periods) and capitation payments (care for a patient over a defined period of time where the provider is responsible for all health services consumed). Participants in the study unanimously emphasized the necessity for further evaluations of RPM programs. Economic modelling and additional assessments were recommended to determine the sustainability and effectiveness of RPM across various patient populations, and to identify payment models that could encourage high-value care pathways. However, implementing such models may face challenges, including the need for coordinated policy changes and the risk of uneven resource allocation, particularly in rural settings where resources are already limited [35, 42].
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