Challenges and recommendations in the implementation of audiovisual telemedicine communication: a systematic review

Ritunga, Imelda; Claramita, Mora; Widaty, Sandra; Soebono, Hardyanto; Imelda Ritunga; Mora Claramita; Sandra Widaty; Hardyanto Soebono

doi:10.3946/kjme.2024.305

Korean J Med Educ > Volume 36(3); 2024 > Article

Ritunga, Claramita, Widaty, and Soebono: Challenges and recommendations in the implementation of audiovisual telemedicine communication: a systematic review

Review Article

Korean J Med Educ 2024; 36(3): 315-326.

Published online: August 29, 2024

DOI: https://doi.org/10.3946/kjme.2024.305

Challenges and recommendations in the implementation of audiovisual telemedicine communication: a systematic review

Imelda Ritunga^1,²

, Mora Claramita³

, Sandra Widaty⁴

, Hardyanto Soebono⁵

¹Doctoral Program, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

²Department of Bioethics and Medical Education, School of Medicine, Universitas Ciputra, Surabaya, Indonesia

³Department of Medical Education and Bioethics, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

⁴Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

⁵Department of Dermatology and Venereology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

Corresponding Author: Imelda Ritunga (https://orcid.org/0000-0001-9648-2611) Doctoral Program, Faculty of of Medicine Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako, Sekip Utara, Yogyakarta, Indonesia Tel: +62.0274.6492500 Fax: +62.0274.581876 email: imelda.ritungan@mail.ugm.ac.id

Received March 16, 2024 Revised May 24, 2024 Accepted June 19, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

This systematic review aims to identify the elements of doctor-patient communication in telemedicine, emerging challenges, and proposed recommendations. Four databases, including Science Direct, PubMed, Cochrane, and ProQuest, were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria consisted of original research papers, availability of free full text, and publications during the past 10 years. A total of 13 articles completed the selection process and satisfied the established criteria. The issues and recommendations of telemedicine communication were categorized into three distinct groups: pre-consultation, during-consultation, and post-consultation. Preparation encompasses the arranging of visual elements, safeguarding patient privacy and confidentiality, and addressing any technical challenges that may arise. The consultation encompasses nonverbal behavior, empathy, the doctor-patient connection, and a physical examination. Post-telemedicine consultations refer to medical appointments that occur after a telemedicine session, typically involving follow-up medical interactions. Telemedicine presents unique challenges in doctor-patient consultations that differ from face-to-face interactions. Therefore, clinicians must acquire communication skills specific to telemedicine to ensure effective consultations and achieve optimal health results.

Keywords: Doctor-patient communication, Doctor-patient relationship, Telemedicine communication, Video consultation

Introduction

Telemedicine continues to play an important role in clinical medicine following the coronavirus disease 2019 pandemic [1]. Experts now consider telemedicine consultations a valuable and beneficial form of media for addressing most common health concerns [2]. Beyond its high utilitarian value, pre-pandemic studies also reported high levels of patient satisfaction [3-5]. Recent research shows that telemedicine provides long-distance specialist care, which is especially useful for those living in rural areas; minimizes hospital visits for vulnerable populations, such as children and the elderly; makes health care more accessible for patients who have trouble traveling to the hospital; and reduces travel time and costs [6-8]. Telemedicine currently widely serves various treatment needs and follow-up, including monitoring chronic conditions, delivering prompt information, administering medication, tracking laboratory test results, conducting radiology tests, scheduling appointments online, handling repeat prescription requests, and facilitating other routine treatments [9,10].

Despite its apparent benefits, communication in telemedicine may be more difficult than typical in-person consultations. Communication is an important aspect that affects health service quality, patient satisfaction, patient health outcomes, and doctor-patient relationships [11,12]. Doctor-patient communication plays an essential role in decision-making, exchanging information, improving the doctor-patient relationship, handling patient doubts, dealing with emotions, and improving self-management [13]. Good communication helps patients feel more confident in their medical professionals and, as a result, improves their overall satisfaction. Patients feel they are receiving better care when there is trust between them and their physicians [14]. Insufficient communication makes it more difficult to establish a doctor-patient relationship via telemedicine. Previous research found that patients felt less engaged in telemedicine consultations compared to in-person meetings [3,15]. In fact, it is estimated that only 7% of emotional communication occurs verbally, while 22% is communicated through tone of voice and 55% through body posture, gaze, and eye contact. These more subtle aspects apparently pose some challenges via telemedicine because the patient and physician are not actually meeting face-to-face but in a virtual “real-time.” Meanwhile, compared to actually consulting in the same room, the dynamics observed in a video consultation can be very different from the traditional in-person consultation [16].

The quality of telemedicine communication is different from that of in-person meetings because some communication elements cannot be applied or have limited application. Additional challenges exist in conducting certain communication components through telemedicine, such as the constraints on interpreting non-verbal behavior [17]. Previous studies showed that telemedicine consultations had less empathy, praise, and support than in-person consultations [18,19]. Non-verbal communications including body language and eye contact are prone to misperception in telemedicine consultations, even though these aspects are important in doctor-patient interactions, especially in building trust in the consultation relationship. In telemedicine doctor-patient communication, the effect of using body language can be significantly reduced or even lost. For example, patients may use non-verbal gestures that show a lack of understanding or disapproval [20].

Telemedicine communication differs from in-person communication. Hence, doctors need to comprehend the appropriate manner of communication, given the importance of effective communication in a medical consultation. Current studies on patient-doctor communication in telemedicine are still partial, they only discuss parts of elements of communication, such as only discussing non-verbal aspects, gestures, or technology [21-23]. Therefore, research on the overall communication between doctors and patients in telemedicine is needed. The goals for this systematic review are to (1) identify elements in doctor-patient communication in telemedicine; (2) find challenges that arise in doctorpatient communication in telemedicine; and (3) propose recommendations that can be applied to anticipate challenges that arise in telemedicine communication.

Methods

This systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify the elements of doctor-patient communication in telemedicine and emerging challenges with proposed recommendations [24]. Searches were performed on PubMed, Science Direct, Cochrane, and ProQuest databases. The keywords used in the search using PICO (Population, Intervention, Comparison, and Outcome) are P=“Doctor telemedicine” OR “Physician telemedicine,” I=“Communication doctor-patient in telemedicine” OR “Teleconsultation” OR “Communication skill doctor-patient in telemedicine”, OR “Video Consultation”, C=none, O= “Element communication skill doctor-patient in telemedicine” OR “Factor communication doctor-patient in telemedicine” OR “Basic communication doctor-patients in telemedicine”.

The inclusion criteria include articles published in the last 10 years, using the English language, and relevant articles with full text available. Articles that met these criteria were then thoroughly read and studied to see if they contained a discussion of the challenges and recommendations for telemedicine communication. The articles included in this review were only original research articles. Other articles, such as commentaries, reports, and editorials, were excluded. Articles that met the criteria were then analyzed in depth, and any findings related to challenges and recommendations were collected and tabulated for discussion. Table 1 shows the inclusion and exclusion criteria applied in this study. The article selection process for this study is shown in the PRISMA diagram in Fig. 1.

Results

Based on the systematic review conducted, 13 articles were selected that met the objectives of the research. The details of the studies included in this review are available in Table 2 [21-23,25-34]. After conducting an in-depth analysis of the 13 selected articles, the challenges and recommendations in telemedicine communication were grouped into three categories: preparation for the consultation, during the consultation, and after the consultation. Preparation includes visual setup, patient privacy and confidentiality data, and technical difficulties. During the consultation includes nonverbal behavior, empathy, the doctor-patient relationship, and physical examination. Finally, post-telemedicine consultations include follow-up medical encounters. The findings of this systematic review can be seen in Table 3.

Discussion

Communication is an important factor in improving the quality of telemedicine consultations so that they can be complementary with to in-person consultations. Telemedicine has high user satisfaction due to its ease, affordability, efficiency, cost, and distance. The inability to conduct direct physical examinations, loss of nonverbal contact, and the emergence of privacy and confidentiality issues were found to be the main obstacles in telemedicine consultations [31]. This systematic review found that some communication components that cannot be done using telemedicine can be implemented differently, such as non-verbal behavior, which needs to be verbalized and emphasized with more direct expressions of empathy. Eye contact is especially important to express attention and check patient responses. Various issues arise because of this technology, such as concerns regarding privacy and confidentiality of patient data, in addition to barriers due to network problems, and patients not understanding technology. In providing ideal telemedicine services for patients, more preparation is required than those in face-to-face meetings.

1. Preparation before conducting telemedicine consultation

Telemedicine consultation is different from face-toface consultation in its implementation, so more preparation is needed. Visual appearance is very important because it determines the quality of communication that will be established. For this reason, attention to simple things such as camera setup, lighting, background, and appearance needs to be considered [21,22,26]. The facial expressions of doctors and patients are also important factors in medical consultations. Through expressions, doctors can find out whether the patient understands the doctor’s explanation or even determine the patient’s disease condition. Meanwhile, patients can tell whether the doctor is listening to them well [21]. In telemedicine meetings, facial expressions sometimes do not appear clearly on the screen due to various factors such as camera quality and poor lighting, so that the doctor’s or patient’s face is dark or covered in shadow.

Even though the use of telemedicine makes it easier for most patients to consult a physician, it has given doctors various new tasks and roles. These include additional patient setup (making sure the technology functions and assisting patients with its use), troubleshooting sources of problems with information technology (IT), having IT support and solutions, determining whether a patient is suitable for a virtual consultation, finding an appropriate physical space for “private” video interactions outside of clinic hours, and developing new forms of medical documentation while adjusting to the different ways in which electronic and paper documents and other artifacts were used in consultations [23]. Accordingly, an administrative role is frequently required to facilitate the implementation of telemedicine by physicians [28]. However, the presence of an administrator might also become a problem, since some patients may feel discomfort having other individuals participate in the consultation due to a lack of privacy. Thus, the amount to which the administrative position can facilitate the telemedicine consultation process will depend on the judgment of the physician and the actual patient’s unique circumstances.

Patients expressed concerns that there may be other people around the doctor who can hear the consultation, which can become another challenge of telemedicine service. Telemedicine consultations are vulnerable to information leaks, making the patients concerned that their personal data may be shared without regard to their privacy [22,29,30]. For this reason, consultation in a private environment and confirmation of data confidentiality are an absolute “must-do” [28]. The doctor needs to introduce anyone who can hear the consultation (usually the nurse) and ask whether there are other people around the patient who can hear this conversation [27]. If the patient is accompanied by other people, it is imperative for doctors to carefully consider their word choices in case there is a discussion that is sensitive and should be kept private from other people, such as in the case of an infectious disease or terminal illness. In contrast, another finding showed that telemedicine patients feel safer than in-person consultations. Patients perceived that remote consultations make them more anonymous and less exposed, so they can convey information that they think is sensitive [35].

2. During telemedicine consultation

The main obstacle during telemedicine consultations is the loss of the nonverbal aspect of the consultation. Telemedicine services are conducted with more verbal communication than nonverbal due to lack of physical presence, causing decreased nonverbal behavior. In addition, the use of long-distance nonverbal cues is prone to misperception of the doctor’s behavior; for example, when the doctor turns to take a file, it will be considered an act of neglect. To avoid this dilemma, a recent study conducted by Shaw et al. [27] stated that all activities carried out by doctors need to be conveyed and explained as simply as possible, such as “If I go silent, I’m writing. Okay?” Eye contact can also become a problem in telemedicine consultation. The doctor may see the patient’s eyes on the screen, but if the patient cannot, then this can be perceived as a form of loss of eye contact because it does not appear as if they are looking at the patient, making them feel ignored. In this case, the study conducted by Helou et al. [33] recommended that looking at the camera during explanations and checking the screen periodically could help to resolve or alleviate this situation. In contrast, telemedicine consultations had a positive effect on doctors by enabling them to monitor and correct their expressions in response to the patient’s story [21].

Building relationships in telemedicine consultations requires special attention because they are more difficult to form than in-person visits. Conveying empathy in telemedicine is more challenging because doctors cannot use supportive non-verbal cues, and patients also have difficulty interpreting the empathy given by doctors, thereby reducing engagement. According to Elliott et al. [21], conveying empathy can be done in the simplest form by providing silent time and letting the patient tell their story until they are satisfied. Listening to the patient’s story without interruption can also demonstrate a deeper and more sincere empathy for the patient. Additionally, the study of Gordon et al. [26] recommends building a doctor-patient relationship in telemedicine by encouraging patients to convey their personal opinions, which are solicited through patient-centered questions and more “personalized” treatment.

Telemedicine consultations limit physical contact between doctors and patients, making physical examinations difficult. Research by Gordon et al. [26] found that patients were worried that the physical examination was deficient even though they had received guidance from a doctor online. However, doctors can alleviate patient anxiety and maintain trust by clearly communicating their assessments, seeking assistance from onsite staff, or referring patients for in-person exams when necessary. Additionally, patients’ perceptions may evolve as advancements in telehealth technology enhance the capability to perform physical exams during telemedicine.

3. Post telemedicine consultation

After a telemedicine consultation, the patient may not know when to have another check-up. Therefore, followup is needed to remind patients about the next scheduled visit. Telemedicine consultations should be applied to repeat patients and only need a follow-up consultation, not to establish a new diagnosis. Thus, education and reminders for follow-up control are very important so that patients continue making medical visits.

Virtual consultations were most effective for managing long-term conditions where there was a strong, trustbased relationship between clinician and patient, no need for interdepartmental coordination, and when physical examinations were not necessary. They were particularly beneficial when there were clear advantages to virtual meetings, such as a history of missed in-person appointments or difficulties with patient travel. Both the clinician and patient needed to be confident and competent with the technology, and frequent contact was required. In these ideal situations, video consultations were found to be safe and well-received by both patients and staff, with patients especially appreciating the convenience and the ability to avoid taking time off work [23].

Furthermore, it was found that telemedicine consultations were more suitable for control patients who are already undergoing treatment, such as patients with hypertension and diabetes, since the majority of these patients often do not necessitate a physical examination that would provide support for the follow-up consultation. Research revealed that telemedicine consultations had a shorter duration compared to in-person consultations, potentially due to the prevalence of repeat patients among telemedicine users. Nevertheless, patients with severe conditions or those requiring medical procedures or physical examinations, such as antenatal consultations, cannot be seen via telemedicine [23].

Conclusion

In conclusion, although the implementation of telemedicine is very beneficial for patients, there are still some communication barriers that can affect the quality of consultations. To deal with these emerging obstacles, several practical solutions can be applied, and more preparation is needed in telemedicine consultations. Some limitations of the research are that it only selected articles from the last 10 years, even though telemedicine services have been conducted at the global level for several decades. In addition, technological advances are accelerating telemedicine research, so while this manuscript was written and submitted, there may now be more telemedicine research that is relevant to this study. Our search was also limited to virtual doctor-patient communication, even though virtual communication has very broad uses. If further research is conducted in other fields such as tele-nursing and palliative care, communication components may be found that can be applied to improve telemedicine communication capabilities. While the use of telemedicine is predicted to continue to increase, telemedicine communication is still not widely studied and taught to medical students; therefore, learning the specific challenges and recommendations about telemedicine communication for medical students needs to be done to equip them with good communication skills in conducting telemedicine consultations.

Acknowledgments

The authors would like to thank Septiana Purwandini as research assistant for helpful preparation during the research.

Notes

Funding

None.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contributions

Conception or design of the work: IR. Data collection: IR. Data analysis and interpretation: IR, MR. Drafting the article: IR, MR, SW. Supervision: MR, SW, HS. Review and editing: MR, SW, HS. Final approval of the version to be published: all authors.

Fig. 1.

PRISMA Flow Diagram in this Study

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PICO: Population, Intervention, Comparison, and Outcome.

Table 1.

Inclusion and Exclusion Criteria

Inclusion criteria	Exclusion criteria
1. Original research article	1. Article reviews, commentaries, editorials, or news
2. Available in English/Indonesian	2. Studies on telemedicine that focus on engineering/information tech- nology aspects
3. Available free full text
4. Publications for the last 10 years (May 2014May 2023)

Table 2.

Details of the Studies Included in this Systematic Review

Author (year)	Study design	Participants	Age (yr)	Location	Medical purposes	Findings
Gordon et al. [26] (2020)	Qualitative interviews	27 Patients with type 2 diabetes mellitus	47–78	USA	General medicine	Doctor-patient relationship
Croes et al. [25] (2019)	Experimental	186 Undergraduate students aged 18–32 years	18–32	Netherlands	General medicine	Nonverbal cues and social interaction
Newcomb et al. [22] (2021)	Quasi-experiment	5 Fourth-year medical students and 4 observers	Not available	USA	Surgery	Lighting, gesture, silence, environment, behavior
Helou et al. [33] (2022)	Experimental	43 Japanese and 61 Lebanese	Not available	Japan, Lebanon	General medicine	The importance of eye contact in telemedicine
Elliott et al. [21] (2020)	Qualitative analysis	49,967 Video consultation user comments.	Not available	USA	General medicine	Gesture, expression, emotional support, environment, voice tone
Fatehi et al. [31] (2015)	Cross-sectional	24 Patients with diabetes mellitus	Not available	Australia	Endocrinology	Third party and eye contact
Donelan et al. [32] (2019)	Cross-sectional	254 Patients and 61 physicians	All ages	USA	Oncology and primary care	Physical examination and signal
Alqurashi et al. [28] (2023)	Mixed-method study	81 Health professionals	>18	Saudi Arabia	Various specialties	Privacy and confidentiality
Ditwiler et al. [29] (2022)	Qualitative study	21 Participants	Not available	USA	General medicine	Privacy and confidentiality
Legido-Quigley et al. [30] (2014)	Qualitative study	12 Participants	Not available	EU	Teleradiology	Privacy and confidentiality
Greenhalgh et al. [23] (2018)	Mixed-methods study	36 Stakeholders, 30 remote consultations, 17 in-person consultations	All ages	UK	Diabetes and cancer surgery	Technical problem, non-verbal behavior
Shaw et al. [27] (2020)	Qualitative study	37 Telemedicine, 28 in-person; 37 staff, and 26 patients interviews patients	>18	UK	Diabetes, heart, and cancer	Technical problem, non-verbal behavior
Hamel et al. [34] (2018)	Secondary analysis	231 Video-recorded oncology interactions	Not available	USA	Oncology	Patient-centered communication, expression, and gesture

Table 3.

Findings of Elements, Challenges, and Recommendations of Doctor-Patient Communication in Telemedicine Consultation

Theme	Telemedicine communication elements	Challenges	Recommendations	Resources
Preparation	Visual setup	Poor visual appearance causes patients and doctors to be unable to interpret each other’s expressions.	Camera adjustments: Installing a high-resolution camera close to the screen makes it easier for doctors to see the screen and make eye contact.	[22,25,26]
			Proper lighting: Ensure the face is clearly visible through sufficient lighting. Ifnatural lighting is not enough, it can be helped by using a ring light.	[22,27]
			Background setting: Limit distracting clutter behind the doctor caught on camera.	[21,22,26]
			Physician professional appearance: Position your head to shoulders clearly captured by the camera in the center of the screen with a straight gaze and dress professionally.	[21,22,27]
	Patient privacy and confidentiality data	Patients do not open during the consultation because they are worried about leaks of privacy or personal data.	Private environment: Physicians conduct telemedicine consultations in a quiet place without the presence of other people.	[21,22,28]
			Confirm the presence of a third party: Both parties need to introduce who can hear the consultation, such as nurses or family.	[27]
			Reliable procedures: Informing patients that telemedicine will be conducted according to procedures and ensuring that their confidential data is safe.	[29,30]
	Technical difficulties	Consultations are disrupted due to technical problems such as signal interference, audio that is not connected, or patients who are not trained in using technology.	Audio confirmation: Begin by greeting and asking, “Is my voice heard clearly?” In addition, patients are advised to bring paper and a pen just in case the sound is not heard.	[26]
		Patients do not know how to operate equipment for telemedicine.	Accompaniment by closets people: Assistance to operate telemedicine by a nurse, and/or family member is required.	[31]
			Technical set-up: Physicians need to make test calls so the patient can familiarize themselves with the technology and/or check that the video and audio work before the consultation.	[23]
		Communication is not smooth due to network problems.	Anticipate bad network: Poor audio quality in two consultations required patient and clinician to communicate via telephone, muting the sounds while simultaneously running the video display.	[23,32]
During telemedicine consultation	Nonverbal behavior	There are limitations in conveying nonverbal communication.	Eye contact: Stare at the camera while explaining, occasionally glancing at the screen to check the patient's expression.	[22,26,31,33]
			Purposive gesture: Make deliberate movements to show focus and enthusiasm, like nodding, pointing fingers, and more.	[21,25]
			Expression: Expressions that align with body movements can build patient rapport and trust.	[21,34]
	Empathy	Doctors cannot convey maximum empathy.	Physician’s silence and focus to the patient: Silence, not interrupting the patient’s conversation, and focused listening can be the first steps in conveying empathy online.	[21,22]
			Verbalized empathy: Express empathy in verbal forms such as “It hurts when going through a divorce; it must be very difficult. You have done your best to survive, and I will try to cure you.”	[22,26]
	Doctor-patient relationship	Long distance meetings make it difficult to form a doctor-patient relationship, making it difficult for patients to express opinions. Inaddition, the limited camera capture makes patients misinterpret the doctor’s behavior, such as looking down when taking notes, turning their head, and so forth, as an act of neglect.	Narrate behavior: Asking permission before doing something can minimize misinterpretations such as “I will note down your complaint,” including silence in listening with “I will listen carefully.”	[22]
			Support patient’s confidence: Narrating patient respectful behavior such as “I’ll think for a moment” shows that the physician is focused on listening to the patient’s complaints.	[22]
			Provide emotional support: Doctors try to understand the patient’s feelings. Doctors need to ask direct questions regarding the patient’s feelings/emotional situation when these cannot be clearly assessed on the screen.	[21,22]
			Encourage the patient’s opinion: Using patient-centered questions and treatments, encouraging patients to ask questions and express opinions actively.	[26]
			Not rushed: Be calm and carry out consultations during working hours so that you are not rushed. Time limitations can be overcome by providing brief and efficient explanations.	[21,26]
			Pitch, speed, volume of sound: It is necessary to set a standard tone and volume that conveys the doctor’s friendliness. A fast way of speaking is considered to show enthusiasm and mastery of the speaker’s material.	[21,25]
			Shared decision making: Increasing effort in understanding patient massages. Provided different treatment options, gave different ideas	[21]
	Physical examination	Inability to perform a physical examination	Accompanied by closest people: Assistance is required to conduct simple examinations by a nurse, and/or family member.	[31]
			The need for direct examination: Recommend that patients come to the hospital for further observation for serious conditions.	[32]
Post telemedicine consultation	Follow-up medical encounter	The patient did not make a repeat visit.	Follow-up medical conformity: Plan the next meeting by considering patient preferences/situation.	[21]

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