This project is being conducted (July 2022-June 2025) in two remote Indigenous communities in the NT, where health care is provided by either NT Government-run health services or ACCHSs. Health services across the NT were invited to express their interest in participating in the project. A project advisory committee, consisting of key decision-makers from the NT and Commonwealth Health Departments, ACCHSs, and stakeholder partners, selected the sites based on community size, remoteness, location (Top End, Central Australia), health service delivery and governance model (government, ACCHS), and estimated readiness to engage with DHTs. This approach sought to maximize the opportunity to evaluate and compare the findings from diverse communities with different governance structures. The clinics in these communities are mostly staffed by remote area nurses, AHPs, and nonclinical administrative staff based in the community, with visiting (and sometimes telehealth) services provided by general practitioners, Allied Health Professionals, and various medical specialists. The NT has unique cultural, social, and language considerations, with 26.3% of the population identifying as Aboriginal or Torres Strait Islander (compared to 3.2% across Australia) [23]. In remote and very remote communities of the NT, more than 90% of the population identify as Aboriginal, and for many, English is not their first language [23]. The participating communities in our project meet this unique NT profile: they are small (<400 population), very remote, and have a predominantly Indigenous population. They face numerous health care delivery challenges and have differing usable technological infrastructure, such as the presence of a 4G mobile network, the presence of microwave, satellite, or cable internet, and the presence of community Wi-Fi.

A participatory action research (PAR) methodology actively involves key stakeholders, including patients (consumers), health care providers, caregivers, and community members in the research process. This methodology emphasizes collaboration, shared decision-making, and engagement of those directly affected by the research [24,25]. The intention is that a network of participants who are actively engaged in the project can help bridge the gap between research and practice to create sustained system change.

We will apply three theoretical frameworks in the design, implementation, and evaluation of DHT solutions in the 2 communities. First, an overarching logic model (Figure 1 [26]) for CPHC will be used to provide a systematic approach for data collection across the different components of a CPHC system (context, inputs, enablers, outputs, and immediate, intermediate, and outcomes), and the contribution of each component will be monitored against relevant outcome measures [27].

Second, the six dimensions of the modified theory of access—acceptability, accommodation, affordability, accessibility, availability, and awareness (including digital health literacy)—will be used to evaluate the impact of DHTs in providing enhanced access to CPHC [28,29].

Third, a realist approach will be used to explore which DHTs work, for whom, and under what circumstances [30,31]. Realist evaluations go beyond simply determining whether an intervention is effective or not; they provide insight into underlying mechanisms and the context of causal relationships between interventions and outcomes.

This tri-part approach is likely to be especially useful to unpack the complex interplay of factors operating within remote and Indigenous health care environments [30,32].

Specific research questions include:

The project will be conducted in multiple phases, including investigation and co-design of DHTs with consumers and health service staff, iterative implementation of different DHTs in two community sites, and evaluation of these DHTs on consumer and staff experiences and access to CPHC (refer to Figure 1).

Community partnership is an important aspect of this project. It is crucial to understand how remote communities experience access to CPHC and how DHTs may improve or deter their access to and experiences with health services. A total of 6 stakeholder groups were identified as crucial partners in this project (refer to Table 1 for details). Briefly, group 1 includes community leaders, group 2 includes consumers, and group 3 includes health service staff, health board members, and clinical and nonclinical staff at the participating sites. Likewise, group 4 includes project partner organization staff, group 5 includes technology provider organization staff, and group 6 includes other stakeholders and thought leaders. Participants must be aged 18 years or older and able to provide informed consent.

This is a multi-institutional collaboration that includes government and industry partners [43]. The key partners include the Digital Health Cooperative Research Centre, the Commonwealth Department of Health and Aged Care, the NT Government, the NT Primary Health Network (NTPHN), the Aboriginal Medical Services Alliances NT, Healthdirect, the Australian Digital Health Agency, the Menzies School of Health Research, and the University of Sydney. Representatives from each partner provide substantial research and industry input at all stages of the project.

Table 1 provides a summary of data sources used at each stage as the project progresses.

Initial workshops and key informant interviews with thought leaders will be used to develop primary health care journey maps that depict how different DHTs are being used. Barriers and enablers of access to CPHC and the role of DHTs in improving access will be discussed to identify initial outcomes and mechanisms.

Interviews with stakeholders will be used to explore their perspectives on various barriers and enablers of access to CPHC and the role of DHTs in improving various aspects of access. Focus group discussions with consumers in the communities will explore key challenges and identify their preferences. A baseline survey, including the BWS survey, will collect data on DHT coverage, consumer experiences with DHT use [37,38], eHealth literacy [36], and consumers and health staff preferences for DHT implementation [40,41].

Once preferences of consumers and health care providers regarding DHTs are identified and feasible DHTs are implemented and optimized, focus group discussions, interviews, and surveys will be used to collect data about consumer use and satisfaction. This will be an iterative process and will inform scalability to other remote Indigenous communities.

Secondary administrative data will be retrieved from multiple sources, including CPHC data at the two intervention sites, such as utilization data, hospitalization, and patient transport data. These analyses will complement scalability and economic analyses. Expenditure and personnel data (eg, workforce composition and supply) required for economic analyses will be obtained from the participating organizations. Further secondary data needs will be determined once the DHTs are prioritized (refer to Table 1).

This project is situated within the governance of the Strengthening Our Health System Strategy, an established collaboration of Aboriginal Medical Services Alliances NT Health (the state health department), and NT Primary Health Network. It focuses on crucial aspects of the NT Virtual Care Strategy [6] relating to improving equity, delivering culturally safe services, and providing support, resources, and guidance for staff about how and when digital health care is effectively provided. It is overseen by a Project Control Group and a Project Advisory Group, each having representation across all partner organizations and the Commonwealth Department of Health. Around 3 additional working groups (the research working group, project operational team, and technical working group) hold responsibilities for guiding research activities, ensuring smooth project delivery, and navigating technology issues in the implementation and adaptation of DHTs for CPHC in remote NT.

This implementation project has Indigenous leadership and representation, including as chief investigators, and at all stages, including design and implementation. This project also uses 1 male and 1 female community-based Indigenous researcher at each study site. The community-based researchers are mentored by experienced research team members and have been provided with training on ethical conduct in research, data collection, and analysis, and they provide reciprocal cultural mentoring for non-Indigenous research team members.

Knowledge translation is an integrated feature of the project and is of particular interest to stakeholders and other partners in the project. The governance structure enables rapid feedback on project developments and outcomes. Sharing findings with stakeholders, health services, funders, and executive groups (eg, NT Health and the Commonwealth Department of Health) will be prioritized to inform the scalability and suitability of DHTs for CPHC in other remote Indigenous communities. Customized reports will be provided to each of the stakeholder groups and participating services. A one-page, plain-language report will also be distributed to the participating communities and all NT remote health services. The lead researchers and local community-based Indigenous researchers will present findings to key members of the community. Where necessary, Aboriginal community-based researchers will help interpret the findings in the local language. Dissemination will include peer-reviewed publications and presentations at conferences and professional workshops.

The project was reviewed and approved by the Human Research Ethics Committee of the Northern Territory Department of Health and the Menzies School of Health Research (HREC approval no 2022-4275). Administrative approval was also obtained from the Research Governance Office, NT Health (EFILE2023/8720), and from the Boards of any participating ACCHS. Research project approval was also sought from the respective land councils, and appropriate travel and work permits were obtained for each site to support community-based research activities.

This project aims to optimize the use of DHTs to improve access to CPHC in remote Indigenous communities. DHTs, including telehealth, have been used ad hoc or as pilot projects rather than for mainstream ongoing health care delivery [47]. While there are promising findings from other studies in the NT [14,16], to the best of our knowledge, our project will be the first to co-design DHT interventions with consumers and remote health providers and to systematically evaluate the acceptability and effectiveness in remote Indigenous communities.

Key findings from this project will include community preferences and priorities for digital health, the co-design process of the digital health initiatives, and learnings from implementation and evaluation. The findings will provide evidence on the impact of digital health initiatives on access to health care and remote community and health provider experiences. Barriers and facilitators to implementing these initiatives will help inform learnings for future DHT implementations in remote communities.

The involvement of multiple stakeholders, including consumers, health service providers, technology partners, and policy and funding partners, is critical to improving the knowledge about and skills for using DHTs to provide CPHC in remote communities [24,48]. The use of one DHT (telehealth) to improve access to CPHC has been examined in remote NT, and it has been reported that the doctors were able to provide more clinical care because less of their time was consumed traveling to each community [14,16]. This project considers a broader range of DHTs, extending beyond telehealth to include, for example, SMS text messaging for appointment reminders, medication reminders, health promotion messages, community health portals, and use of the Australian Government’s My Health Record. The intention is to improve access to CPHC, promote equity, and improve health outcomes in the two remote communities through improved continuity of care and fewer avoidable hospitalizations and patient transfers. Effective and acceptable CPHC also capitalizes and contributes to increased trust and long-term relationships with health service providers to increased cultural security, greater convenience in receiving health care, a reduction in health care disparities, and stronger community engagement in health management and well-being [6,14].

The economic analysis is unique, as previous studies have not reported such systematic evaluations. The virtual care strategy of NT Health [6] has reported that digital health has the potential to save AU $6.3 million (US $4.095 million) on annual travel costs and AU $950,000 (US $617,500) on the cost of appointment cancellations in the NT (1 AU$ =0.65 USD). However, these estimates are not based on community-based studies from the NT. Our economic evaluation intends to show the financial benefit at the local level for the clinic and patient, which will inform decision-making about implementing DHTs in CPHC.

Unintended consequences are not uncommon in the digital health space, and one such risk is the additional administrative and clinical workload that the resident staff may bear and the concern for burnout [17,47]. The co-design and PAR approach is expected to help identify such issues proactively and address them on time. For instance, additional workload needs to be accounted for when telehealth consultations with outpatient hospital services or health promotion sessions are offered in the community [49].

A second issue is managing the “digital divide” [50,51]. Cautious and informed DHT identification and implementation will minimize the impact of broad-stroke DHT interventions that widen the gap in access to CPHC experienced by disadvantaged populations who may not have digital devices, connectivity, or digital literacy or skills for such consultations [52,53]. The realist approach, by identifying how DHTs work and who needs support, why, and in what circumstances within the available provisions, adds further critically important information regarding approaches to DHT implementation in marginalized populations such as those living in remote Indigenous communities [30,31].

A third issue is managing perceptions that telehealth may be “a cheaper option” for CPHC in remote communities [10]. In an ideal situation, the same clinical staff would always be available face-to-face for consultations, but in many remote communities, this is not realistic due to high staff turnover, declining general practitioner training enrollments, vast geographical distribution of the smaller communities, and the inequitable distribution of resources [8,27,54]. This project will identify opportunities to implement DHTs that do not take away existing face-to-face services but rather complement and enhance CPHC in remote communities. The DHT interventions may be catalysts to improve health and well-being in remote Indigenous communities.

There are important limitations to consider in this study. Due to the small remote community population sizes, the sample included in the studies will have limited statistical power but will have inclusive consideration for the remote communities. Poor digital connectivity and high staff turnover, including changes in the health service administration, are also beyond the control of our project team. The use of secondary administrative data that have not been collected for the express purpose of the study is likely to present additional challenges. For example, the ACCHSs and government health services use different patient information management systems, limiting the ability to link datasets and the comparability of data available at different sites. Despite its strengths, the PAR approach is time-consuming, needs additional efforts to focus on processes, and has the potential to lead to friction among the stakeholders due to competing priorities [24,25]. While it can be counterproductive if not handled with care and expertise, this has been accounted for in the project design and development strategies, which are founded on the considerable expertise of the research team. The credibility and local ownership offered by the PAR approach outweigh these limitations.

Digital innovations have affected every aspect of our lives. It is unlikely that the current health system and health service delivery can remain isolated from such a rapid proliferation of innovative DHTs. This project provides a unique opportunity to optimize and systematically evaluate key digital health interventions. It will also highlight why DHTs work for some but not for others, identifying risk groups to create appropriate supports within the community. Furthermore, the economic analysis will help the local health board and other stakeholders make an informed decision to adopt, refine, or reject DHTs in the future. In conclusion, the project has the potential to substantially improve access to CPHC services for the remote Indigenous communities of the NT. Such improved access will help improve the health outcomes of those living in remote communities.