Over the past decade, healthcare providers have started to take advantage of advanced technologies to expand and improve the delivery of services to patients through telehealth. Telehealth is the provision of health services from one location to another using a telecommunications medium such as the Internet, computer network, telephone, or related technologies.1
Many professions, including radiology, pathology, and home healthcare, have adopted systems of telehealth to improve patient access while reducing the costs of their services. Hearing care is at an early stage of telehealth, but its use is expected to expand rapidly with the introduction of new diagnostic and treatment telehealth applications.
A report from PricewaterhouseCoopers says that “telehealth services are expected to exceed $1.8 billion by 2013”2 and, the federal government is expected to invest $6 billion in telehealth programs.3 We now find companies such as AT&T, Verizon, and medical device manufacturers aggressively entering this market, with proponents anticipating significant cost savings to the healthcare system.
Howes4 and Krumm1 describe several systems of telehealth currently in use in hearing care, including:
* Self-guided tools provided to patients for self-assessment or management. These might include hearing tests taken online or delivered through phone applications or tools that patients can use to make minor adjustments to their hearing devices.
* Real-time and live interactive telehealth, which are synchronous applications that put patients and service providers in live contact via the web, telephone, or other technology. Peripheral devices such as remote audiometers or video-otoscopes could be attached to computers or video-teleconferencing systems to aid in patient examination. This approach to telehealth might include counseling or management applications.
* “Cloud-based” or “store and forward” asynchronous service delivery whereby patient information can be transmitted or delivered off-line for later review. The information, including digital images, video, or other clinical data, is stored and can be transmitted (forwarded) for future viewing. If, for example, these are test results such as a hearing or vestibular evaluation, they can be viewed by the specialist for interpretation or review.
The goals of telehealth include increasing access to services for patients who are far from or lack transportation to service providers; permitting services to be provided in a place convenient and natural for the patient; facilitating the benefits of continuity of care, resulting in enhanced outcomes; and potentially reducing costs, both to providers and to the patient and family by saving travel costs, time off from work, and associated costs such as child care.5
Congress included telehealth services in the Balanced Budget Act of 1996 (BBA). This legislation called for “coverage and payment for telemedicine consultations to Medicare beneficiaries in rural areas where there is a shortage of health professionals.” (www.telehealthlawcenter.org/?c=127).
When the BBA passed, the Centers for Medicare and Medicaid (CMS) limited Medicare reimbursement to live real-time telemedicine services. However, Congress amended the law in 2001 to expand payments for telehealth services. While still restrictive in the types of reimbursable services and the methods of service delivery that are covered, the amended legislation included funding for demonstration projects of store-and-forward applications in Alaska and Hawaii.
In 2009, Congress introduced H.R. 2068 “to improve the provision of telehealth services under the Medicare Program, to provide grants for the development of telehealth networks, and for other purposes.” Services provided by qualified licensed practitioners will be reimbursed if this legislation passes. The ultimate goal has been to pave the way for broader private-pay reimbursement.
CMS has not formally defined telehealth for Medicaid, but states have been given the option of approving reimbursement for telehealth services. At least 27 states, recognizing the cost efficiency of telehealth, now provide some level of reimbursement for such services. It is widely assumed that private insurance generally does not reimburse for telehealth services. However, the Center for Telehealth and E-Health Law reports that more than 100 private insurers now pay for such services.6
Professional associations have begun to recognize the value of telehealth and telepractice to improve access to audiology services. The American Speech-Language-Hearing Association (ASHA) and American Academy of Audiology (AAA) have both developed position statements in support of and about the use of telehealth and telepractice in audiology.
The AAA states that “diagnostic and rehabilitative telehealth/telemedicine services should always be provided by, or supervised by, a qualified practitioner; should be primarily provided to individuals who have limited access to providers in their communities (e.g., homebound); and services should be validated before implementation…”7
Similarly, ASHA states that “telemedicine is appropriate for audiologists…but that the quality of telepractice services should be equal to that of services dispensed face-to-face.” Further, ASHA notes that “long-term outcome measures are needed…to determine efficacy and cost effectiveness of telemedicine applications…[and that] telemedicine appears to be a practical and progressive method to meet the needs of clients who need greater access to services.”8
Among the most widely discussed issues surrounding telehealth is the role of state licensure. State laws define the legal requirements to practice in that state. Therefore, practitioners providing services to patients in a different state pose significant challenges to a state-based licensure system.
Consider the scenario of a patient from New York who spends the winter in Florida. Must the healthcare practitioner be licensed in both states to manage the patient? In the past decade, many state boards have begun to address this topic. In nursing, for example, a “mutual recognition model” was developed allowing a nurse with a license in one state to practice in other states if the nurse agrees to abide by the laws of the other states where she or he practices. Twenty-three states have adopted this “interstate compact” in nursing (www.telehealthlawcenter.org/?c=143).
Since physicians have also been finding a greater role in telehealth, the Federation of State Medical Boards established a committee that developed a model bill containing an abbreviated licensure process for physicians who are licensed in one state but provide services to patients in another state. To date, 15 states have adopted plans allowing other states to have jurisdiction over physicians providing services within their borders (www.telehealthlawcenter.org/?c=155).
In 2005, a task force from the Academy of Doctors of Audiology (then called the Academy of Dispensing Audiologists), the Audiology Foundation of America, and AAA developed a model license law in response to changes occurring in the audiology profession. That model law had sections permitting “telecommunications and information technologies for the exchange of information from one site to another for the provision of audiologic care to an individual at a distance from the provider through hard-wire or Internet connections.”
In addition, the model law contained guidelines to permit a licensed audiologist in one state to provide telehealth services to a patient in another state. It appears, however, that very few state boards in audiology have acted on the role of telehealth in hearing care.
TELEHEALTH IN HEARING CARE
In 2004, the Starkey Group, Inc., introduced its first telehealth service with GoToAssist, a tool in the Inspire software that offered practitioners live access to audiologists in customer service at Starkey who could assist with a difficult fitting. This synchronous service was enhanced in 2008 with Audiology OnDemand. In 2009, the company introduced the use of Dual Tone Multifrequency (DTMF) signals emitted by telephone keypads as T2 that enabled patients to adjust the volume and memory settings of their hearing aids with their cell phones.
Now, Starkey has brought these professional tools together with the introduction of Telehealth OnDemand. In addition to the synchronous technology available through Audiology OnDemand, practitioners will be able to make small adjustments to new hearing instruments by using DTMF signals delivered remotely through telephones. This ability meets the standards of care described by Palmer8 to provide immediate access to services at a time and place that is convenient to the patient and, thereby, to control costs without compromising the quality of care.
Practices that offer telehealth services may need to implement protocols such as times of the day or week when patients can schedule remote adjustments and follow-up scheduling to validate the results of the minor adjustments. Whether it is through remote access to customer service or live synchronous adjustments to hearing instruments, telehealth is a professionally focused approach to patient management.
Telehealth services are expanding in every aspect of healthcare and providing synchronous remote access to patients. They were developed and designed to support the clinical activities of busy practices that are committed to providing quality care to their patients.
1. Krumm M: Telehealth: Lessons learned and learning, including considerations in audiology. Presentation at NIDCD Meeting on Affordable Hearing Health Care. Bethesda, MD, 2009.
2. PricewaterhouseCoopers: Telehealth, shared doctor visits, online consultation seen as cures for capacity constraints. Corporate Report, 2009.
3. Siriwardane V: AT&T sets its sights on the “telehealth” industry. Star Ledger NJ Business News
. Newark, NJ, December 6, 2009.
4. Howes C: Technology bridges and barriers. Presentation at Jackson Hole Rendezvous. Jackson Hole, WY, 2009.
5. Palmer C: Policy Issues in Telehealth. Presentation at Jackson Hole Rendezvous. Jackson Hole, WY, 2009.
6. Center for Telehealth and eHealth Law: Medicare reimbursement, 2009.
7. American Academy of Audiology: The use of telehealth/telemedicine to provide audiology services. Resolution 2008–06, 2008.
8. American Speech-Language-Hearing Association, Working Group on Telepractice: Audiologists providing clinical services via telepractice: Technical report, 2005.