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Telepractice

Overview

Telepractice is the application of telecommunications technology to the delivery of speech language pathology and audiology professional services at a distance by linking clinician to client/patient or clinician to clinician for assessment, intervention, and/or consultation.

Supervision, mentoring, and pre-service and continuing education are other activities that may be conducted through the use of technology. However, these activities are not included in ASHA's definition of telepractice and are best referred to as telesupervision/distance supervision and distance education. (See Clinical Supervision in Speech-Language Pathology: Technical Report [ASHA, 2008] for information related to the use of technology in clinical supervision in speech language pathology.)

ASHA adopted the term telepractice rather than the frequently used terms telemedicine or telehealth to avoid the misperception that these services are used only in health care settings. Other terms such as teleaudiology telespeech, and speech teletherapy may be used in addition to telepractice. Services delivered by audiologists and speech-language pathologists are also included in the broader generic term telerehabilitation (American Telemedicine Association, 2010). The use of telepractice does not remove any existing responsibilities in delivering services, including adherence to the Code of Ethics, Scope of Practice in Audiology and Scope of Practice in Speech-Language Pathology, state and federal laws (e.g., licensure, HIPAA), and ASHA policy.

Telepractice venues include schools, medical centers, rehabilitation hospitals, community health centers, outpatient clinics, universities, clients'/patients' homes, residential health care facilities, childcare centers, and corporate settings. There are no inherent limits to where telepractice can be implemented, as long as the services comply with national, state, institutional, and professional regulations and policies.

The two most common terms describing types of telepractice are synchronous (client/patient interactive) and asynchronous (store and forward).

Synchronous services are conducted with interactive audio and video connection in real time to create an in-person experience similar to that achieved in a traditional encounter. Synchronous services may connect a client/patient or group of clients/patients with a clinician, or they may include consultation between a clinician and a specialist (Department of Health and Human Services, n.d., 2012).

In asynchronous services, images or data are captured and transmitted (i.e., stored and forwarded) for viewing or interpretation by a professional. Examples include transmission of voice clips, audiologic testing results, or outcomes of independent client/patient practice.

Hybrid applications of telepractice include combinations of synchronous, asynchronous, and/or inperson services. Clinicians and programs should verify state licensure and payer definitions to ensure that a particular type of service delivery is consistent with regulation and payment policies.

Key Issues

Roles and Responsibilities

Telepractice is an appropriate model of service delivery for audiologists and speech-language pathologists. ASHA requires that individuals who provide telepractice abide by the ASHA Code of Ethics, including Principle of Ethics II, Rule B, which states, "Individuals shall engage in only those aspects of the profession that are within their competence, considering their level of education, training, and experience" (ASHA, 2010).

Roles and responsibilities for audiologists and SLPs in the provision of services via telepractice include

Telepractice is constantly evolving. Ongoing education and training is required to maintain expertise and familiarity with changes in technology and potential clinical applications.

Licensure and Teacher Certification

A growing number of states have legal requirements regarding telepractice. See state telepractice requirements. Clinicians should verify state licensure requirements and policies regarding telepractice, both in the states where they are licensed and where they wish to telepractice, prior to initiating services.

Current guidance in medical and legal practices indicates that the client's/patient's location determines the site of service. As a result, telepractitioners must be licensed in both their home states and in the states in which the clients/patients reside. Recognizing that this can be a burden to practitioners and a barrier to the growth of telepractice, ASHA is encouraging state licensure boards to consider less restrictive alternative models of licensure. Civilian employees of the Department of Defense and the Department of Veterans Affairs may not be bound by the same licensing requirements. Confirm the specific licensing requirements for your circumstances.

ASHA is also working with a coalition of other provider organizations to address the issue of licensure portability for the use of telepractice (Brannon, Cohn, & Cason, 2011, 2012).

Clinicians planning to do telepractice in a school setting in a state other than where they reside should verify with the Department of Education and the licensure board whether licensure or teacher certification, or both, are required.

International Considerations

ASHA-certified audiologists and speech-language pathologists who deliver telepractice services to individuals in other countries are bound by the ASHA Code of Ethics and other official ASHA policy documents that guide ethical and appropriate practice. Prior to providing international telepractice services, it is important to

Reimbursement

Before initiating services verify that funding source(s) will cover services delivered via telepractice. (See FAQs on Telepractice Reimbursement and Licensure). Telepractice providers should be prepared to educate payers about how telepractice services are delivered and the benefits to clients/patients and payers. Education materials include research articles, organization policies and procedures to assure provider training and quality services, educational/informed consent materials for clients/patients, video clips, and testimonials.

Private Health Insurance

There is a trend for states to pass legislation mandating coverage of telepractice. Generally, the mandates require health insurers, subscription plans, and health maintenance organizations to cover the cost of health care services provided through telepractice on the same basis as those provided through in-person visits. Insurers may reimburse for telepractice in states without mandates; however, given the variability of state requirements, the practitioner should first check with the payer.

Medicare

Medicare reimburses some telemedicine providers for specific services under specified conditions, but audiologists and speech-language pathologists and other rehabilitation professionals are not presently included in legislation as eligible providers. ASHA and other organizations have been actively lobbying for legislation to expand eligibility to include audiologists and speech-language pathologists among others.

Medicaid

Medicaid is a federal/state entitlement program for low-income individuals and families. Each state

Some states have explicitly authorized reimbursement for telepractice by audiologists or speech-language pathologists or have established a general trend for reimbursement of telehealth. Practitioners should contact the appropriate state Medicaid office to verify how a telepractice service should be reflected in the billing code and documentation.

Self-pay

Services that are not covered by private insurance or public payers may be paid for out of pocket by the client/patient, provided the services meet all other relevant legal and ethical standards.

Client/Patient Selection

Because clinical services are based on the unique needs of each individual client/patient, telepractice may not be appropriate in all circumstances or for all clients. Candidacy for receiving services via telepractice should be assessed prior to initiation of services. The client's/patient's culture, education level, age, gender, and other characteristics may influence the appropriateness of audiology and speech-language services provided via telepractice.

Consider the potential impact of the following factors on the client's/patient's ability to benefit from telepractice

Environmental Considerations

Attention to environmental elements of care is important to ensure the comfort, safety, confidentiality, and privacy of clients/patients during telepractice encounters. Room location, design, lighting, and furniture should optimize the quality of video and audio data transmission and minimize ambient noise and visual distractions in all participating sites.

Advance planning and preparation is needed for optimal positioning of the client/patient, test and therapy materials, and for placement of the video monitor and camera (Jarvis-Selinger, Chan, Payne, Plohman, & Ho, 2008).

Practice Areas

The growing body of research on the use of telepractice for communication disorders includes many studies demonstrating the comparability of telepractice and in-person services.

Audiology

Computer-based clinical applications are common in audiology today (Choi, Lee, Park, Oh, & Park, 2007; Kokesh, Ferguson, Patricoski, & LeMaster (2009). For example, audiometers; auditory brainstem response (ABR), otoacoustic emissions (OAEs), and immittance testing equipment; and hearing aid systems are frequently computer peripherals, which can be interfaced to existing telepractice networks. Manufacturers are now promoting equipment with synchronous or store-and-forward capabilities.

Practice areas where teleaudiology is being used include

Speech-Language Pathology

Telepractice is being used in the assessment and treatment of a wide range of speech and language disorders, including

Modification of Assessment and Treatment Techniques and Materials

Clinicians who deliver telepractice services must possess specialized knowledge and skills in selecting assessments and interventions that are appropriate to the technology and that take into consideration client/patient and disorder variables. Hence, assessment and therapy procedures and materials may need to be modified and adapted to accommodate the lack of physical contact with the client/patient. These modifications should be reflected in the interpretation and documentation of the service.

School Setting Considerations

Stimulated by shortages or maldistribution of clinicians in some school districts, distances between schools in rural districts, and opportunities to offer greater specialization of services within a district, schools are currently the most common setting in which telepratice services are delivered. Telepractice contracts may be developed with the local education agency or school district, or the services may be provided by audiologists and speech-language pathologists employed by the district. Some states authorize Medicaid reimbursement for eligible students in schools.

The effectiveness of telepractice as a service delivery model in the schools is well documented (Grogan-Johnson, Alvares, Rowan, & Creaghead, 2010; Scheideman-Miller et al., 2002; McCullough, 2001; Grogan-Johnson et. al., 2011; Lewis et al., 2008; Waite et al., 2006).

In addition, parents, clients, and clinicians report satisfaction with telepractice as a mode of service delivery (McCullough, 2001; Rose et al., 2000; Scheideman-Miller et al., 2002; Crutchley & Campbell, 2010).

The administrative body responsible for defining telepractice-based services in a school or school district should

Telepractice Technology

The use of technology is an inherent element of telepractice. Specifications and selection of the appropriate equipment and connectivity vary according to the telepractice application. Technical support and training in the use of telepractice equipment are essential for success; further, these needs will be ongoing as technology continues to evolve.

Videoconferencing Equipment (hardware, software, and peripheral devices)

Video communication can be accomplished through the use of personal videophones, videoconferencing software, and dedicated videoconferencing hardware and computer-based secure web-based progams. Factors/options in the selection of video conferencing equipment include

Connectivity

During telepractice, information is transmitted across a telecommunications connection (e.g., point-to-point, dedicated line, web-based) between participants at different sites. Consider the following factors in determining appropriate connection strategy

Facilitators in Telepractice for Audiology and Speech-Language Services

Although only certified and/or licensed audiologists and speech-language pathologists can provide professional services via telepractice, appropriately trained individuals may be present at the remote site to assist the client/patient. Unless restricted by institutional or state policies or regulations, the facilitator may be a teacher's aide, nursing assistant, audiology assistant or speech-language pathology assistant, teleaudiology clinical technician, telepresenter or other type of support personnel, interpreter, family member or caregiver, among others.

The type of paraprofessional required at the remote site may vary depending on the type of service being provided. It is the responsibility of the audiologist or speech-language pathologist to direct the session and ensure that the facilitator is adequately trained to assist. Adequate training includes knowledge of and sensitivity to cultural and linguistic differences of clients/patients, as well as the ways such differences may influence participation in telepractice. The hierarchy for preferred interpreters in telepractice is consistent with that used for interpreters during in-person practice. Practitioners must also be aware of applicable state policies and regulations on the use of facilitators.

State and Federal Laws and Regulations

Practitioners should be aware of federal and state regulations relating to privacy and security, including those pertaining to storage and transmission of client information.

Privacy and Security

Clinicians providing services via telepractice are bound by federal and state regulations as they would be when providing in-person services. Federal legislation about privacy and security for covered entities include the Health Insurance Portability and Accountability Act of 1996 (HIPAA; U.S. Department of Health and Human Services [HHS], n.d.), the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH; HHS, n.d.), and the Family Educational Rights and Privacy Act of 1974 (FERPA; U.S. Department of Education, n.d.). States may also have privacy or security requirements that are more stringent than federal requirements. (See Health Insurance Portability and Accountability Act for general information about HIPAA. See also HIPAA Security Rule: Frequently Asked Questions, HIPAA: Electronic Data Interchange (EDI) Rule, and HIPAA Security Technical Safeguards.)

Determining how to be compliant with these regulations is complex. There are no absolute standards that dictate which software programs meet all requirements. For example, a vendor cannot guarantee that a product is HIPAA-compliant, because the policies of the provider and how a program is implemented are variables that help determine the effectiveness of the program's privacy and security measures. Consulting an expert who specializes in these issues is advisable. Further discussion of the complexities of privacy is provided by Cohn and Watzlaf, 2011.

Security of treatment rooms and remote access to electronic documentation must be considered to protect client/patient privacy and confidentiality at both sites. Clients/patients should be given an opportunity to decide who should be present at their locations when they receive services, and a camera may be used to scan the clinician's environment to ensure privacy. All persons in rooms at both sites should be identified prior to each session or when the individual(s) enters the session.

To manage risk, clinicians are advised to obtain documentation of informed consent from the client/patient. This may include a description of the equipment and services to be delivered, how services via telepractice may differ from services delivered in person, any modifications that will be made in assessment protocols, and potential confidentiality issues. Documentation may also include the type of equipment used, the identity of every person present, the location of the client/patient and the clinician, and the type and rate of transmission.

It is the clinician's role to ensure client/patient confidentiality when telepractice services are used. In order to do so, clinicians must have knowledge of

Enlisting Stakeholder Support

It is essential for practitioners to gain the support of stakeholders-including clinicians, administrators, sponsors/payers, technical and support staff, teachers, multidisciplinary team members, students and parents, and clients and family members/caregivers-when implementing a telepractice program. Without understanding, planning, collaboration, and a receptive attitude toward telepractice on the part of all stakeholders, a program that has been launched can fail.

Methods for enlisting support include

Resources

ASHA Resources

Frequently Asked Questions: Telepractice

Model Language for Interstate Telepractice [PDF]

State Telepractice Requirements

Organizations

American Telemedicine Association

Center for Connected Health Policy

Center for Telemedicine Law

Office for the Advancement of Telehealth

VHA Office of Telehealth Services

References

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