Though numerous applications of telehealth exist, Laura Coco, AuD, said most methods can be classified into two categories: asynchronous, such as the store-and-forward and remote monitoring approaches, and synchronous or real-time telehealth, which includes mobile health and live interactions. In the store-and-forward approach, images and scans are taken in one location and sent to an off-site provider for review. “With this method, a patient would go to a satellite site to receive hearing services, but diagnoses would not be made until a practitioner has access to the patient's information,” explained Evelyn Davies-Venn, PhD, AuD, an assistant professor in the department of speech and hearing sciences at the University of Minnesota.
Technology allows for the store-and-forward method to provide immediate results if a clinician is available to make and relay diagnostic or treatment information, but a potential disadvantage of this model lies in the lack of ready care. “If information is sent and a practitioner is not available to receive it right away, there is potential for inconvenience to the patient,” Davies-Venn said. “If the facilitator makes an error, there would be no opportunity to immediately rectify it. In that case, a patient will usually go to see an audiologist in person because she or he will want immediate answers and treatment,” she continued, adding that that largely defeats the purpose of remote care.
Coco noted that in addition to potential patient inconveniences, the store-and-forward method has a large disadvantage for providers compared to other methods: It can impede upfront compensation or reimbursement. The Center for Connected Health Policy (CCHP) reported that only 11 U.S. states have policies in place for store-and-forward reimbursement. In comparison, 20 states hold policies for remote patient monitoring reimbursement and 49 states have policies for live video reimbursement. Further restrictions within the 11 states that reimburse store-and-forward care include limitations to specialties covered, specifications for what type of data can be transferred, and geographic licensing requirements. Despite the restrictions, the store-and-forward method is particularly useful in areas with limited internet connection and can be a vital resource for patients, Coco said.
Another method of teleaudiology, remote monitoring, which includes self-monitoring and self-testing for chronic diseases, is showing a lot of promise, Davies-Venn said. “Mobile phones have become ubiquitous and present unique opportunities we didn't have years ago,” she said. Mobile apps such as hearScreen USA are revolutionizing at-home hearing tests, enabling patients to self-detect hearing loss, connect with verified audiologists, and even set up appointments in-app. In addition, various hearing aid manufacturers offer apps that allow patients to self-adjust hearing aids. “Apps such as these are powerful for patients,” Davies-Venn said. “Anybody can download it and take a noise test created by an audiologist and auditory scientist,” she said. “With audiology apps, patients can test their hearing on their own and have a database of audiologists who are ready to receive clients, answer questions, and see teleaudiology patients,” she said. “It's a great opportunity for patient-initiated hearing health care services.”
In contrast to asynchronous methods, a popular synchronous method emerging around the country is mobile health, such as a clinic in a truck that comes to the patient. Organizations including the Veterans Affairs and the University of Alabama have seen great success in mobile audiology clinics that can help offset backlogs of patients who are unable to visit traditional sites. Marcia Hay-McCutcheon, PhD, CCC-A, an associate professor of communicative disorders at the University of Alabama and the founder of its Hear Here Alabama mobile audiology clinic, said the truck has provided the opportunity to reach counties in Alabama that have not had access to hearing health services for several years.
Their 40-foot long truck is outfitted with a hearing aid analyzer, two computer-based audiometers, two tympanometers, two video otoscopes, and two single-walled sound booths. The truck and its equipment allow Hay-McCutcheon and her team, often consisting of audiology students, to go to health fairs in surrounding counties and help those who otherwise would not have been able to receive hearing care. “We have been able to identify people who have hearing loss by providing hearing evaluations to those who need help,” Hay-McCutcheon said. “An important part of our work is not only to help people get hearing aids but to also learn about the importance of those hearing aids and to get social support to make them successful hearing aid users,” she added. “Our goal is to use the truck as a vehicle for support in communities; we'd like to set up support groups for those who are just starting to wear hearing aids led by people who have prior experience, such as a trained community health worker.”
Live interactions, another synchronous teleaudiology method, involve the use of video and audio equipment to facilitate a live interaction between patients and practitioners. For those seeking to introduce teleaudiology to a private practice, this method provides a choice that is simpler to implement than something as extensive as a full mobile clinic. “The basic tools a clinician needs to facilitate a live interaction with a patient include a computer, a web camera, a microphone, and a high-speed internet connection,” Coco said. “A teleaudiology service can use essentially the same equipment used in a traditional face-to-face audiology clinic, with the addition of web cameras and remote desktop software to connect the patient and clinician sites,” she added. For an even simpler offering of services, Davies-Venn said equipment purchases could be next to none. “It all depends on what services you want to provide,” she said. “If you are doing mobile otoscopies and screenings, you may only need a smartphone and an accessory that can use the camera in your phone, such as a magnetic specular that attaches to the lens of your camera phone. With that equipment alone, you can cut video and send it to yourself for later examination.”
Recent innovations have also allowed clinicians to complete more complex care that may have seemed impossible just a few years ago. “Patients are often surprised that, using teleaudiology equipment, an audiologist can see their eardrum and program their hearing aid from hundreds of miles away,” Coco said. “Clinicians who are unfamiliar with teleaudiology may even be surprised to learn that nearly every service provided in a traditional in-person clinic can be performed remotely via teleaudiology, from infant auditory brainstem response to cochlear implant mapping,” she continued. In late 2017, the U.S. Food and Drug Administration (FDA) approved remote programming for the Nucleus Cochlear Implant System for patients with at least six months of experience with their cochlear implant sound processor, greatly reducing the time spent by patients traveling to an office for subsequent programming. Further FDA testing of remotely programmable cochlear implants in a clinical study of 39 patients aged 12 or older revealed no significant difference between in-person and remote programming.
In other mobile service scenarios, Davies-Venn said, clinicians mail equipment to the patient directly, who performs the required test themselves and sends the results back to the office. “In some models, patients can use a laptop that has earphones mounted to it that are calibrated to do at-home hearing tests,” she said. If funding equipment is an impediment, Coco recommended adopting teleaudiology in small increments. “Clinicians can begin by communicating with patients over email or telephone and offering follow-up sessions via video conferencing platforms rather than face-to-face,” she said. By encouraging patients to download apps on their own devices, clinicians can also take advantage of remote hearing aid programming and feedback through the app directly.
Though teleaudiology has shown great results and even greater promise, it is important for clinicians considering introducing teleaudiology to their practices to consider risks, ranging from limitations of technology to missed medical interventions. “Though [teleaudiology] may seem like a direct option for providers to conduct patient interactions, there may be a host of technological limitations on both sides of the care continuum,” Coco said. “Services delivered via synchronous teleaudiology can mimic traditional face-to-face care, but this approach may have logistical challenges: A high-speed, secure internet connection is needed so that the patient and clinician sites can communicate without interruption,” she said. “Technology is a great vehicle that can bring about equality and access to care, but it can also be a great divider,” Davies-Venn agreed. “A lack of financial or physical sources could impede teleaudiology care,” she continued. “Patients may not be able to afford reliable WiFi or they could be living in a place where high-speed internet is not available,” she said.
For mobile clinics such as the Hear Here Alabama truck, lack of high-speed internet access is one of the biggest challenges the group faces when providing care. “We need to have broadband [internet] to perform teleaudiology care,” Hay-McCutcheon said. “The lack of broadband services across the state is the primary reason we have not incorporated teleaudiology more prominently. If statewide access became a reality—if every little nook and cranny had access—our impact would be huge,” she said. Even for those who have reliable internet access, patients may still be weary of using technology to receive hearing care. But for those who are comfortable with technology, self-driven models have a lot of potential, Davies-Venn said. “If a device is not working or patients are not satisfied in a certain situation, they don't have to wait two weeks for an appointment with a clinician to make an adjustment—they can make it right there with the help of teleaudiology,” she said.
The greatest risk comes from the reliance on technology to be the eye of the clinician, Davies-Venn said. “With teleaudiology methods that involve no live patient interaction whatsoever, there is a risk of either delaying or missing medical intervention and causing further damage,” Davies-Venn said. “In certain cases, the eye of a skilled practitioner may be the difference in identifying a patient that doesn't simply need a hearing aid turned up but has a growing tumor that is causing damage, for example,” she said. Having a skilled professional available and engaged somewhere in the process is a good idea, regardless of the teleaudiology model in use, she said. “It's important to reach a middle point where the clinician engages with the patient or a facilitator so they are involved in diagnosing patients and can mitigate some of the larger care concerns,” she said. “We as clinicians have to be mindful of potential obstructions and consider them when designing new models of delivering hearing health care.”
In addition to direct patient care concerns, the practicing teleaudiologist must be mindful of HIPAA regulations and patient privacy protection. “Teleaudiology services must adhere to the same HIPAA regulations as face-to-face services,” Coco said—though adhering to those regulations can be more challenging when not in the traditional office environment. For some remote services, a facilitator must be present at the patient site to help with hands-on tasks, including orienting the patient to the equipment and helping with communication, Coco said, something that could introduce a potential patient privacy risk. “Patient-site facilitators are not typically health care professionals and do not directly provide diagnosis or treatment, but they are important to the success of the services a clinician provides, and therefore their training and supervision are crucial,” she said.
To mitigate those concerns when mobile, Hay-McCutcheon said the Hear Here Alabama truck is divided into areas similar to a brick-and-mortar office. “When you walk into the truck, there is a general intake area and two exam rooms with accordion doors where we can talk with patients privately,” she said. One booth is large enough to accommodate three to four people, allowing clinicians to share information with patients and their families or caretakers while still maintaining privacy, she added. To maintain HIPAA compliance when working with the store-and-forward, remote monitoring, or real-time telehealth approaches, clinicians must be vigilant about preventing security breaches, Coco said. “Internet network connections must be encrypted and secure, and additional consent processes may be needed,” she said. “In addition, if you are engaging in synchronous teleaudiology using a live video and/or audio connection, for patient safety and confidentiality, each individual in the room should be named, and each time someone enters or leaves the room, that will need to be announced.”
The Voice over the Internet Protocol system that will be used to facilitate the video conferencing connection must be HIPAA-compliant as well, she added. “As technology becomes more sophisticated, the digital divide widens, separating those who have access to the internet or those who are comfortable with technology from those who do not,” Coco said. “We are responsible for understanding this divide and minimizing it, including through patient-centered design, and by respecting individuals’ cultural characteristics and health literacy.”
Though undertaking the addition of teleaudiology to a clinical practice may seem intimidating, Coco, Davies-Venn, and Hay-McCutcheon agree: The benefits outweigh the risks. “One of the challenges a clinician faces when training to practice in teleaudiology is a change in mindset,” Coco said. “Teleaudiology is a different way of delivering services, and for many of us, it does not reflect the way we were first trained to interact with patients,” she said. Clinicians may fear the quality of care can suffer with teleaudiology because they are not face-to-face with their patient, she added. “Teleaudiology is a new way of delivering services, and therefore we need to learn appropriate adaptations, including how to establish rapport with patients using online communication.” Coco said this is sometimes referred to as “webside” manner. “I have been impressed by how quickly patients and providers can achieve good rapport while interacting through a video conferencing platform,” she said. The clinician and patient may feel awkward at first, and the setup requires some getting used to, but “even individuals who are less familiar or comfortable with technology seem to only take a few minutes of casual chatting on the video screen, and before you know it, the setup feels normal,” she said.
To adapt to the technological side of teleaudiology, Davies-Venn recommends completing market research to see what specific needs are in your community. “The first step is to determine what patients really want—not what we think they want,” she said. Look at your community's current immersion in technology and see if there is a space that is experiencing a great amount of innovation and build from that, she advised. “Teleaudiology has a unique benefit if we can determine the best models to use in different environments,” Davies-Venn continued. “Once your research is done, determine what technology is best to use and get good IT support.” That support can come in the form of other clinicians who have implemented teleaudiology in their own practices or from national organizations that provide resources to interested practitioners, Coco said. “Talk to other clinicians who have experience integrating teleaudiology into their existing practices or seek out professional organizations for information, education, and support,” she said. Those organizations include the American Telemedicine Association; ASHA's Special Interest Group 18, Telepractice; and the IDA Institute's free telecare tools, a set of online resources for patients and clinicians, including content on preparing a patient for your first audiology appointment.
With your teleaudiology practice in full swing, don't forget to look for unique markers of success. “To determine the success of your teleaudiology program, you'll want to set goals relevant to your mission, and collect outcomes aligned with those goals,” Coco said. Your markers of success may be patient-centered outcomes, such as satisfaction or clinical markers, or provider-centered outcomes, such as referral patterns, she said. “Identify the specific activities that you will be providing and identify measurable performance targets. You might document the number of travel miles patients save by using teleaudiology as a measure of cost and time savings, for example,” Coco added.
If you're still on the fence, take a second to really consider what the addition of teleaudiology could mean for your community, Davies-Venn said. “The need for teleaudiology is greater than the supply in terms of the amount of skilled practitioners who have added remote services to their practices,” she said. And when in doubt, take this final piece of advice from Hay-McCutcheon: “Go for it. Just take the bull by the horn and do it.”
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