Exploring advantages and challenges of synchronous video telehealth

Telehealth has persisted as a critical care delivery option in the post-COVID-19 public health emergency (PHE) landscape. Adoption and utilization of telehealth remain far higher than pre-PHE levels; however, this spike in telehealth use revealed the vast digital divide that prevents vulnerable communities from reaping the technology’s benefits.

There are several types of telehealth, including synchronous video, asynchronous, and audio-only telehealth. Each type has unique advantages, use cases, and challenges. Here, mHealthIntelligence will explore synchronous video-based telehealth.

WHAT IS SYNCHRONOUS VIDEO TELEHEALTH?

Synchronous telehealth refers to live, real-time patient-provider interaction via audio-visual technology, according to the United States Department of Health and Human Services (HHS). In this telehealth setting, patients communicate directly with their clinicians, enabling diagnoses, decision-making around treatment plans, and follow-up care.  

Synchronous video-based telehealth visits mimic in-person care in many ways, with the patient and healthcare provider having face-to-face discussions. Clinicians can observe the patient’s appearance, breathing, and musculoskeletal range of motion via video and get a sense of their mental state, as noted in an article published in the Journal of General Internal Medicine.

However, other devices are needed to enable some aspects of the in-person examination, such as vital sign measurement. For instance, patients can use remote patient monitoring (RPM) devices, either personal devices or ones sent by their healthcare facility, to take vital sign readings and share the data with the clinician before or during a video visit.

Though synchronous telehealth includes audio-only virtual care, HHS data reveals that video visits are more widely used. Between July and August 2022, 53 percent of US adults participated in video visits compared to 47 percent who utilized audio-only telehealth.    

SYNCHRONOUS VIDEO TELEHEALTH BOOSTS CARE DELIVERY

Synchronous video visits have proved beneficial for both patients and healthcare providers.

For one, research shows video visits positively affect clinical care, particularly for those with chronic conditions. According to a study published in December 2023, video visits provide increased appointment flexibility, minimize travel-related burdens, and offer healthcare providers valuable insights into patients’ home environments. The study was based on qualitative interviews with clinical faculty about their experiences with virtual care from June to December 2020.

Additionally, intra-hospital use of video-based telehealth can enhance care efficiency. For instance, a study published in 2023 showed that video-based telehealth limited pediatric hospital transfers more effectively than audio-only telehealth.

For this study, researchers analyzed data for 696 children with acute illness who sought care at one of 15 rural and community emergency departments in northern California between November 18, 2015, and March 26, 2018. Thirty-six percent of the pediatric patients received video telehealth consultations, and 64 percent received telephone consultations.

Researchers found that 84 percent of patients receiving the video telehealth consultation were transferred to UC Davis Children’s Hospital versus 90.6 percent of those who received telephone consultations.

Further, clinical evidence shows that video-based telehealth is not inferior to in-person care. Published at the end of 2023, a sweeping review of research on telehealth shows that live video telehealth is as effective as in-person care in treating certain conditions, like mental health conditions.

Researchers reviewed 80 studies published between January 2021 and October 2022. They found that live video visits have a preponderance of evidence — which means the majority of the studies reviewed are consistent in their findings — showing that they are on par with in-person care in terms of health outcomes, care processes, and utilization of other healthcare services.

As video visit adoption and use grew, even communities that have traditionally had reservations about virtual care delivery came around to the care modality.

Surveys conducted by RAND Corp. in February 2019, May 2020, August 2020, and March 2021 revealed that Black Americans' willingness to participate in video-based telehealth grew during the COVID-19 pandemic. Willingness increased from 42 percent in February 2019 to 67 percent in March 2021 among Black adults.

However, Black Americans’ use of synchronous video-based telehealth is still lower than White Americans, revealing an enduring gap in telehealth access and use among vulnerable populations.

FACTORS CURBING SYNCHRONOUS VIDEO TELEHEALTH USE

Despite the apparent advantages of telehealth, social determinants of health (SDOH) factors like the digital divide curb access for many who would benefit most from virtual care.

Survey after survey reveals that utilization of synchronous video-based telehealth varies across racial and ethnic groups. Data released by HHS in 2022 showed that White respondents reported having an overall telehealth use rate of 21.1 percent but had a higher proportion of video visits (61.9 percent) than audio-only (38.1 percent). While 26.8 percent of Black respondents said they used telehealth the month prior, this population had a higher proportion of audio-only visits (46.4 percent) than White respondents. 

The survey, which polled 808,368 adults across all 50 states and Washington, D.C., also revealed that video telehealth use was higher among those between 18 and 24 years (72.5 percent), college graduates (67.4 percent), and those with private health insurance (65.9 percent) than their respective counterparts.

Additionally, research shows that patient sociodemographic factors influenced whether a telehealth video visit was successful. After analyzing 137,846 video visits for primary and specialty care between March 1 and December 31, 2020, researchers found that Black patients and patients between 66 and 80 years old were more likely to have unsuccessful video visits.

Broadband availability is one of the most significant barriers to synchronous video-based telehealth use. According to independent research conducted by BroadbandNow, 22 million Americans did not have access to a broadband internet connection meeting the 25 Mbps download/3 Mbps upload threshold in April 2024.

A study published in 2022 showed that veterans who engaged in video-based telehealth the most frequently had access to the highest levels of broadband availability. For the study, researchers gathered data on 6.9 million veterans receiving care before (Oct. 1, 2016, to Feb. 8, 2020) and during (March 1, 2020, to June 30, 2021) the COVID-19 pandemic.

Patients who resided in areas with reliable broadband access had higher rates of video visits, the study found. Veterans with optimal broadband participated in 16 additional video visits per 100 patients per quarter than those with inadequate broadband.

Another significant factor limiting synchronous video visit use is language barriers. According to a study where researchers analyzed 955,352 telehealth visits within Kaiser Permanente Northern California between March 16 and October 31, 2020, patients with limited English proficiency used video visits less frequently than patients who did not have limited English proficiency. More specifically, the odds of patients with limited English proficiency attending a video-based appointment were 47.2 percent, while the odds for those without were 49.1 percent.

Low-income populations are also less likely to use video-based telehealth. In a study published in 2023, RAND Corp. researchers examined data from 30 multi-site federally qualified health centers (FQHCs) in California between February 2019 and August 2022. These FQHCs cared for approximately 1.3 million lower-income people.

They found the share of audio-only telehealth dropped from 67 percent in April 2020 to 21 percent in August 2022, while video visits rose from 4 percent to 7 percent for primary care.

Healthcare providers, too, find conducting video visits challenging for several reasons. A 2021 survey of 337 primary care physicians found that while 86 percent of physicians felt that video visits were an important tool for reaching patients, 60 percent said that the quality of video visit care was worse than what they could provide in person.

A majority (92 percent) of physician respondents noted challenges related to conducting physical exams during video visits. In addition, 45 percent said creating rapport was harder during video visits than in person.

Thus, as healthcare provider organizations continue to incorporate synchronous video-based telehealth into care delivery models, they must do so while breaking down telehealth access barriers and advancing health equity.