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Virtual health care solutions; utilizing both synchronous and asynchronous communication in a clinic setting.

With the explosion of virtual health care solutions, it is easy to get lost in what exactly it is different technologies offer. Each new solution has unique advantages, and each solution will impact different team members in different ways. Understanding what a new virtual health solution offers is key to its successful adoption.  

Development of a telehealth strategy within clinics is important, so that the offerings are comprehensive for patients, but are also efficient and fit in with the clinic’s workflows.     

A complete telehealth strategy includes the use and integration of several technologies, which can be categorized according to how they are used. A useful division is categorizing telehealth into synchronous and asynchronous communication.  

Synchronous Communication: This includes any technology that facilitates real-time communication between either patient and provider, or between providers. Both parties are present at the same time, an example of this could be a provider video-conferencing with patient.   

Asynchronous Communication: This is technology where the two parties do not need to be present at the same time. The most prevalent example is email. There are many e-consult platforms that use asynchronous communication.  

These two categories of communication in health care are best to be thought of as complementary methods, each with their own strengths and limitations.  

Asynchronous communication, such as e-consult, allow for messages to be sent at an individual’s convenience. When a physician has a relatively straightforward question, an e-consult can really benefit. Questions about an abnormality on a lab result, for example, can often be well suited to this type of communication. Where it can be limited is when the question is more open ended, there are many factors for consideration, or a back and forth is required. In these cases, e-consults can become arduous, as there can be lags of days to weeks between communication. 

It is in these circumstances where synchronous means of communication are most effective. Having a conversation in real-time allows for clarification of responses, and more specificity about a patient's condition. Where a specialist may recommend a medication in an e-consult, a real-time conversation will allow for the specialist to explain how they titrate a medication, what they look for when making medication changes, or specific signs or symptoms they look for in the history and physical exam. It also allows physicians to discuss uncertainty, or concerns they may have that they can’t quite articulate in a limited e-consult.  

The limitation of synchronous communication has always been the difficulty of obtaining real-time access to physicians, as it requires schedule alignment. Solutions have previously included a dedicated hotline or on-call service, but these did not solve workflow problems. Paging, phone calls, voicemails can all be interruptive to specialist physicians on-call. These interruptions burden specialist physicians and studies have shown impacts on cognitive load, reduced working memory (Walsh 2014) which can contribute to medical errors.  

What has been overlooked however, is that in our increasingly mobile world, there are technological solutions that solve these problems. Specialist physicians can provide availability on real time schedules, and when they are not incapacitated with other work, so they can direct their attention to providing effective advice. Primary care providers can send referrals for phone advice, giving the specialist background on the patient, and setting the stage for a collegial chat and the betterment of the patient. These hallway chats have been ever-present in medicine, and by using technology to improve the efficiency of these connections, there is potential to bring greater quality to the care of patients, and improve the relationships between providers.  

Technological solutions are continually being developed to address inefficiencies in health care. Solutions must enhance care without compromising efficiency. Synchronous and asynchronous communication methods can be effective ways of improving care, each with their own strengths and limitations.    

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