The pandemic became the flashpoint that brought mainstream exposure to the mental healthcare gaps inherent in America’s health system, particularly access to timely and quality care. As a result, there has been a rapid and compulsory transformation taking place where innovative and evidence-based virtual care and other digital tools have seen accelerated adoption. Telehealth strategies are now playing a larger role in supporting existing care protocols that provide improved access, scalability, and care capacity.
Telehealth incorporates various aspects of virtual care and has emerged as one of the fastest-growing segments in healthcare. Telehealth can be broken into four distinct types: synchronous, asynchronous, remote monitoring, and mobile heallth1. While it can be said that an ideal telehealth solution would incorporate each of these types, the asynchronous model remains one of the most overlooked. This could be attributed to a lack of understanding of how asynchronous fits into a telehealth strategy or the assumption that telehealth must include video.
While synchronous was the first of these types to face scrutiny in mental healthcare delivery, virtual video visits have become widely popular and effective in augmenting mental healthcare. The same stigma that was associated with synchronous utilization is now impacting the value perceptions asynchronous can deliver. "It's a technology [asynchronous] whose time has not yet come," says Oliver Lignell, vice president of virtual health at health system consultancy AVIA, which helps members accelerate their digital transformation initiatives. "It's not yet mainstream, but it should be."2 As virtual therapy sessions become standard practice, the distinctive and untapped value of asynchronous to increase access to quality care will become indisputable.
Difference Between Asynchronous and Synchronous
In the context of telehealth, synchronous refers to the delivery of health information in real-time between a patient and clinician. Asynchronous, also known as store-and-forward, is when the patient and the clinician do not need to communicate at the same time.3 Another way to look at this is synchronous technologies displace clinician and patient engagement geographically; asynchronous goes one step further to also decouple the time when the communication takes place.
A simplified example of asynchronous is it allows for people to share information (text, email, video, audio) online via a health platform, an app, or both. This information is then reviewed, processed, and a response is then sent back to the individual from a provider. The provider may be a health coach, care manager, LCSW, nurse, clinician, or other depending on the platform, the care team, and the condition being treated.
Benefits of Asynchronous
Integrating asynchronous technologies into care workflows has provided clear benefits for both patients and providers. However, it needs to be said that asynchronous models show both clinical and cost-effectiveness when part of a digital therapeutic solution, i.e. digital therapeutics, like SilverCloud Health, that is rigorously researched, evidence-based, and clinically agile to meet the varying patient needs across the continuum.
For patients, asynchronous telehealth provides immediate and always-on access to therapeutic content, tools, and journals. When used in conjunction with guided support from a provider, asynchronous models have shown clinically reliable outcomes on par or better than face-to-face sessions. As a care extender, asynchronous models help maintain a relationship with the provider in between weekly therapy sessions. Considering there are 167 hours between weekly sessions, there is a tremendous opportunity to provide a continuity of care with online evidence-based treatments, support, and motivational communications to improve adherence and capture rich and insightful patient engagement data.
"One of the most important things asynchronous communication does is help scale response," says Ann Mond Johnson, MBA, MHA, CEO of the American Telemedicine Association. "In addition, because patients can use it with a phone or the internet, it can address issues of access.”2
For providers, asynchronous telehealth platforms provide quality care delivery that is consistent, clinically proven, and scalable. Content and tools can be added, updated, and quickly delivered via a one-to-many model without disruption to care while immediately notifying patients of any changes. A patient’s entire care journey is measurable throughout the week, day or night, to show engagement, outcomes, and user satisfaction, all of which can be mapped to HEDIS and other performance metrics to validate value-based care. An online registry consolidates patient data to provide real-time population health analytics that can be quickly assessed and actioned to enhance decision-making. The patient registry also helps coordinate care more effectively and efficiently at a healthcare systems’ level, particularly when broader care teams are involved.
A paper published last year by John Torous, et al., in the Journal of Medical Internet Research points out that the greatest growth in scalability and access to quality care can be attributed to asynchronous. “The COVID-19 crisis has (at least temporarily) removed implementation barriers to synchronous telehealth through regulatory changes, and the evidence, safety, and engagement were already in place before. The next steps to use apps toward asynchronous telehealth will require a continued effort but yield even greater increases in access to high-quality care."4
Figure 1. Digital Mental Health and COVID-19: Using Technology Today to Accelerate the Curve on Access and Quality Tomorrow, John Torous et al.4
Advantages Over Synchronous
To highlight some specific advantages of asynchronous vs. synchronous, asynchronous telehealth platforms are achieving market-leading clinically reliable outcomes on par with both synchronous virtual and in-person therapy. What asynchronous does is effectively reduce the cost per patient encounter and improve outcomes per dollar spend.
As mentioned earlier, a well-researched and designed digital mental health platform benefits from “baking-in” well-thought-out and proven therapeutic protocols, so what is presented to patients is consistent, deliberate, and meaningful. Asynchronous then provides patients with the ability to access and work through behavioral health programs on their own time and at their own pace. They are not rushed on a video call; there is no time pressure, stigma is reduced, they are able to write well-thought-out journal entries and answers to exercises, which helps patients become more empowered to help themselves.
Another consideration is that a clinician may spend the same amount of time on a synchronous video call as with an in-person session, while asynchronous typically requires significantly less time. For example, during the same time as a 45-minute video session, a coach using an asynchronous platform can review and respond to between 4-6 patients, perhaps more depending on how well versed a provider has become with asynchronous therapy.
In the case of SilverCloud’s digital mental health platform, it’s important to note the patients are getting (CBT) therapy through the platform, and the coaches provide human support, guidance, and motivation to complete the treatment. With this model, coaches are very effective at driving PHQ9 down. This is an effective and efficient method for managing populations that do not require a therapist in person or virtual sessions. However, within primary care as an example, the coach plays a critical role in evaluating the appropriate course of care, whether stepping a patient up or down a treatment path and collaborating with broader care team members, i.e., PCP, care manager, or therapist.
A Cautionary Tale
While I have pointed out key benefits of asynchronous mental health, it is important to note that some online mental health solutions offer text therapy allowing users to text their therapist “24/7.” This is misleading and brazen in a number of ways. For one, the coaches or therapists typically do not respond in real-time unless a scheduled chat. Most coaches or providers agree to respond once a day, Monday through Friday. This is not "24/7" therapy. Other solutions commit to responding within a 2-3 day period; this is closer to email than texting. It can also be classified as asynchronous, but I have not included text therapy as a modus operandi in this asynchronous evaluation. There is little research to support its effectiveness.
In a recent article in The Cut, Dr. John Torous, the director of digital psychiatry at Beth Israel Deaconess Medical Center and leader of the American Psychiatric Association’s Health IT Committee, said, “The research on text therapy is very limited. A 2019 study showed “marginal evidence” to support text messaging as a treatment approach for depression and concluded that more research was needed.”5
The asynchronous model proves to be agile, effective, and efficient for health plans and systems. Its impact on the cost of care and the movement towards value-based care will help propel the model to become more mainstream. With the full potential of telehealth still being realized, asynchronous will have a growing and important role to play in virtual care strategies.
About the Author
Derek Angove - Market and Competitive Intelligence Manager at SilverCloud Health
A product marketer by trade, Derek has over 11 years of experience delivering innovative product, marketing, and communications strategies to build market share and drive business growth. Derek has been with SilverCloud for over six years, evaluating the digital mental health landscape. He is responsible for analyzing the global market, investor, consumer, and competitive trends to inform corporate development strategies.