California was one of the earliest U.S. states impacted by the COVID-19 pandemic, and has since gone on to notch case numbers higher than anywhere else in the nation. In early March 2020, operations at our audiology clinic were projected to be significantly and negatively impacted by restrictions and safety measures necessary to protect community health. To maintain our patients’ access to high-quality audiological care amid these restrictions and operational changes, we worked with various stakeholders to develop a teleaudiology workflow utilizing existing clinical equipment. This article will discuss the design, implementation, challenges, and outcomes of that model.
PROJECT DESIGN & EQUIPMENT
As of this writing, meaningful COVID-19 exposure is defined as coming in close contact (<6 feet) for 15 minutes or longer with an infected person (CDC, 2020). It is also suspected that … “brief interactions are less likely to result in transmission…” (CDC, 2020). Based on these assumptions, a mitigation-based model designed around reduced face-to-face interaction between patient and provider was created. Time and financial limitations meant that most equipment for this project would need to be readily available or easily acquired with little to no budgetary impact. As such, all equipment in this project was selected based on these constraints.
To start, audiometric testing tools, including a tympanometer, clinical audiometer, and associated transducers, were connected to the standard clinical work station, referred to as the audiometer computer (Fig. 1). Management of patient results, except for video otoscopy, was performed via a computer with a NOAH network database.
A mini-computer, referred to as the sound booth computer, with a hardwired internet connection was placed in the sound booth. This was used to conduct live conferences between the remote audiologist (RA) and the patient, as well as to capture video data when performing video otoscopy. Audio and video externals were connected to the mini-computer, as was the video otoscope. Proprietary audio-video (AV) conferencing technology was used to conduct patient interviews, provide test instruction, and offer counseling.
STAFF ROLES & TRAINING
All audiologists in the clinic, including the supervising clinical audiologist and the audiology clinic medical assistant, were involved in this project. No participant had previous knowledge of this project or its workflow, aside from the lead. The clinical care providers had varied degrees of technology literacy, and only one staff audiologist had previous, though limited, exposure to remote hearing care delivery.
Following a “train the trainer” educational model, two staff audiologists were trained by the project lead, who oversaw the implementation with the first four patients. Prior to testing actual patients, three test individuals were recruited from the office staff for demonstration purposes. A comprehensive audiometry evaluation was performed remotely by the lead audiologist and subsequently by staff audiologist one and two. While these initial testing efforts were performed, direct, in-person supervision was practiced. Subsequent dissemination of practice patterns and care was done by the first two trained clinical staff. Written and video workflows were also created to support knowledge acquisition.
The primary audiology support provider (SP) was a medical assistant whose previous function was primarily clerical/administrative. Additional support was provided as needed by cross-trained medical assistants. The primary and backup support personnel had previous instruction and demonstrated proficiency with tympanometry, video otoscopy, and headphone placement. Previous trainings for these tasks were completed in office as part of an unrelated project. Re-evaluation of proficiencies and skill verification were conducted on all SPs prior to patient testing.
Essential audiology care needs were reviewed for all existing appointments and new referrals during the period in question. Patients were triaged to either remote care audiometry or telehealth phone appointments based on their referral notation. Phone appointments were set to further triage as needed. Patients were offered remote care audiometry appointments if: (1) testing was likely to be successful in this modality and (2) the hearing care need was determined to be essential. If these conditions were met, the patient was contacted. Standardized regional scripting was used to screen for COVID-19. Of note, no patient screened in this project was determined or suspected to have COVID-19.
This sequential workflow is detailed in figure 2. Upon arrival at the facility, patients were asked COVID-19 symptom-related questions, screened for fever, and provided a face mask. In all cases, standard contact precautions were employed by both providers and patients. Once checked in, an AV conferencing session was initiated by the RA from the remote computer to the sound booth computer managed by the SP. The RA then logged on to the audiometer computer via a Windows-based remote desktop connection protocol (RDP). The functionality of all tools (tone presentation, speech stimuli, etc.) was verified prior to rooming each patient. Once systems verification was completed, the patient was roomed by the SP.
Tests were performed in a double-walled, sound-treated booth using standard audiometric testing techniques. The sound booth was connected to the building's HVAC system. Patients were seated in the booth by the SP and introduced to the RA. AV equipment audibility and clarity were verified with the patient by the RA; the SP assisted when needed. The RA introduced the professionals involved and conducted a patient identification and case history interview. The SP performed video otoscopy via the screen-share feature of the AV equipment. The RA provided feedback and direction for otoscopy as well as patient instructions for standard audiometric testing. TDH-39 headphones were applied by the SP, who then departed the sound suite and stayed at a separate location. Tone and speech tests were performed by the RA. Patient responses were repeated aloud in the test environment. Spoken word responses were assessed via the ongoing AV connection. Patients were asked to respond to frequency-specific stimuli by pressing the response button, providing a verbal response, or raising a hand. When bone conduction was deemed necessary, the RA remotely contacted the SP, who was tasked to apply the bone oscillator and adjust headphones as needed for the RA to provide appropriate masking.
Upon completion, the RA advised the patient to remove the headphones, verified audibility with the patient, and conducted counseling and care planning. The SP was then informed via a messaging application that testing was complete and that the patient was ready for discharge. The SP completed the discharge procedure, including provision of any printed materials or setting a subsequent appointment if needed. The sound booth was then cleaned following universal disinfecting protocols.
An on-call audiology provider was in the office during all remote testing to support ENT clinic operations and provide backup to the RA. Additional duties included test provision for individuals incapable of or unsuitable for this care model.
OUTCOMES & CLINICAL INSIGHTS
Success was based on the completion of a standard audiometric test battery to the satisfaction of the RA. Another measure of interest was the presence of any issue(s), regardless of its impact on testing outcomes. A total of 42 patients were tested with this workflow. They all completed a comprehensive audiological examination, including air and bone conduction audiometry, speech recognition threshold, and word discrimination. On the second measure of interest, an operational issue was encountered in two instances, but it was quickly and fully resolved with minimal care disruption (five minutes or less).
At the outset, it was suspected that various factors may contribute to sub-optimal (less than 100%) success, including internet connection, patient or provider attitudes toward technology, equipment problems, procedural errors, and other unpredictable deviations to care delivery. A counter-balancing measure was implemented to avoid appointment loss, but this mechanism was never put into use.
The success of this project indicates the enormous promise in allowing audiologists to employ an easy and affordable remote care model despite individual provider differences. Furthermore, the reduction of face-to-face care delivery time was not insignificant. Time spent providing direct patient care for tympanometry, otoscopy, and headphone placement was markedly less than that typically spent by clinical providents in interviewing, evaluating, and discussing care with a patient.
Additional areas of interest are the attitudes of both patients and providers toward care. For instance, how do patients and providers feel about this delivery model? For example, post-facto attitudes diverged on the amount of time testing would take to provide remote care compared with the normally allocated time for clinical testing (1-1.3:1). Having ideal test populations and additional demographic characteristics would also be useful to best facilitate future implementation for the right populations.
Billing and coding questions surely abound. These matters are beyond the scope of this discussion and should be directed to appropriate professional resources. Diligence and attention should be given to ensuring the security of all patient interactions consistent with all local, state, and federal guidelines. Consulting with your IT and legal teams is paramount in understanding and eliminating unnecessary risks to your practice and your patients.
While this project was undertaken to reduce COVID-19 transmission risk, its implementation and demonstrated success suggest that it is high time to consider diversifying audiology practices such that high-quality care can continue to be delivered safely and effectively. This model is affordable, accessible, and easy to implement using equipment that are available in many audiology practices. It serves a pivotable tool that could enable providers to access patients in underserved areas, mitigate disease-related risks to patients, and even allow for healthy or recovering providers to be active labor participants when they may otherwise remain in precautionary quarantine. With work-life balance being an important concern among younger professionals, this project also demonstrates that work-from-home opportunities can also exist for audiologists.
Editor's note: Mention of technologies used in this article is for demonstrative purposes only, and does not reflect an endorsement by the author. The author thanks his colleagues for their support and tireless work on this project.