Using Translational Research to Support the Evolution of Virtual Care

With the end of the COVID-19 public health emergency (PHE), the conversations surrounding virtual care have shifted. Organizations are less concerned with the rapid deployment of telehealth, instead turning their attention to assessing the value of virtual care and ensuring health equity.

As telehealth use skyrocketed, it became clear that telehealth access was unequal across racial and socioeconomic groups. A study published at the end of 2020 revealed that older age, patients having a language preference that was not English, being of Asian race, and having Medicaid coverage were associated with fewer telemedicine visits.

Research also showed that these disparities persist across age groups and clinical conditions. A study published last year revealed that children living in rural areas were less likely to use telehealth compared with their urban counterparts. In addition, research published in June showed that counties with a Black population exceeding 20 percent of the total population had a 42 percent lower likelihood of using telehealth.

"The hypothesis that telehealth was going to solve a lot of our problems, especially in underserved and rural areas, although it was somewhat successful, one major lesson that we learned was that a substantial number or amount of people was left behind," said Saif Khairat, PhD, associate professor, and Beerstecher-Blackwell Distinguished Term Scholar in the University of North Carolina at Chapel Hill School of Nursing.

To advance translational research in virtual care with a focus on health equity, the University of North Carolina at Chapel Hill established the Center for Virtual Care Value and Equity (ViVE). Launched on August 1, the center will be supported by a $3.73 million grant from the National Institutes of Health’s (NIH) National Center for Advancing Translational Sciences. The center's work will continue for five years.

"We need a mechanism that can explore both venues in parallel: the patient and health equity standpoint and financial sustainability from the organizational standpoint," said Khairat, who will lead the center. "That's how the Center for ViVE came to [be]."

The center will focus on translational research, that is, research that can be translated into actionable tools and frameworks that organizations can use to implement equitable and sustainable virtual care programs.

According to Khairat, the multi-level stakeholder nature of virtual care and the disconnect between them is a significant challenge to conducting translation research in the virtual care arena.

"You've got patients on one end, and then you have the organizations; you also have the providers, and then you have the vendors," he said. "They don't all necessarily talk to each other at the same time. There is good communication here and there, but a cohesive conversation and collaboration is needed."

This collaboration is critical as telehealth remains popular among patients in complement to in-person care. A recent survey that polled 2,202 United States adults in July revealed that 35 percent prefer hybrid care models that combine both virtual and in-person care.

Khairat echoed this idea, stating that as virtual care becomes increasingly integrated into the healthcare delivery model alongside in-person care in the post-PHE landscape. Thus, the need for translation research in this area is high.

Not only that, but conducting this translational research will also be helpful if and when the next PHE strikes.

"Public health emergencies can happen over and over again," Khairat noted. "And it doesn't have to be a pandemic, like what happened. It could be something like a hurricane... Telehealth is, I think, here to stay, and we need to think that we can make it equitable for everyone, sustainable for providers and organizations."

To advance translational research and foster greater collaboration within the virtual care arena, the center will employ a phased approach to its operations.

Currently, the center is in the capacity-building phase, which means hiring and filling jobs to build its teams. Next, the focus will be on developing expertise and gathering data on virtual care. 

"There are scattered datasets here and there on telehealth, but it's very difficult to find a complete and comprehensive dataset that represents EHR data with billing and claims data, with social determinants of health and neighborhood characteristics," Khairat said. "That would give us a good understanding of, 'Okay, where are potential areas of inequities, and where are gaps in payment models that hinder the value of virtual care?' So, our first goal would be to develop this database or data repository."

In doing so, Khairat also hopes to gain insights into strategies for improving virtual care data collection.

Further, the center will allow UNC-Chapel Hill investigators and students at UNC-Chapel Hill interested in virtual care research to request data, engage in consultations with experts in the field, and access education and training events.

As the center builds its teams and data collections, health equity will remain top-of-mind, Khairat noted. The center's research efforts will include interviewing representatives from Native American and other underserved populations to ensure health equity. These populations often have more than one type of social determinants of health (SDOH) challenge impacting their health and ability to access care.

"I think in the past, we've thought about telehealth as a one-size-fits-all," he said. "It hasn't quite worked that way. And that's why more in-depth research [is needed]. So, I think the center is going to be able to represent the voices of many that have been underserved and unheard or maybe not factored in."

He added that because approximately 80 percent of North Carolina counties are rural, UNC is best suited to access and include these previously underrepresented voices in research.

But, collaboration will be essential as the Center for ViVE grows. Khairat said the center will work with other stakeholders, including payers, policymakers, and professional societies, to understand the financial and policy-related hurdles to advancing virtual care. By bringing together these voices, the center aims to develop consensus around frameworks that can support virtual care implementation and sustainability.

"It's really important for me to highlight that it's going be a team sport and a national exercise for people who are interested in this to come together and have a dialogue on how we can improve virtual care," Khairat said.