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
- understanding and applying appropriate models of technology used to deliver services;
- understanding the appropriate specifications and operations of technology used in delivery of services;
- calibrating and maintaining clinical instruments and telehealth equipment;
- selecting clients who are appropriate for assessment and intervention services via telepractice;
- selecting and using assessments and interventions that are appropriate to the technology being used and that take into consideration client/patient and disorder variables;
- being sensitive to cultural and linguistic variables that affect the identification, assessment, treatment and management of communication disorders/differences in individuals receiving services via telepractice;
- training and using support personnel appropriately when delivering services;
- being familiar with the available tools and methods and applying them to evaluate the effectiveness of services provided and to measure outcomes;
- maintaining appropriate documentation, including informed consent for use of telepractice and documentation of the telepractice encounter;
- being knowledgeable and compliant with existing rules and regulations regarding telepractice including security and privacy protections, reimbursement for services, and licensure, liability and malpractice concerns;
- collaborating with physicians for timely referral and follow-up services (Hofstetter, Kokesh, Ferguson, & Hood, 2010);
- using web-based technology to engage clients through virtual environments and other personally salient activities (Towey, 2012).
Telepractice is constantly evolving. Ongoing education and training is required to maintain expertise and familiarity with changes in technology and potential clinical applications.
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.
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
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 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 is a federal/state entitlement program for low-income individuals and families. Each state
- administers its own programs,
- establishes its own eligibility standards,
- chooses the type, amount, duration, and scope of services,
- sets the rate of payment for services.
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.
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.
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
- physical and sensory characteristics, including
- hearing ability,
- visual ability (e.g., ability to see material on a computer monitor),
- manual dexterity (e.g., ability to operate a keyboard if needed),
- physical endurance (e.g., sitting tolerance);
- cognitive, behavioral, and/or motivational characteristics, including
- level of cognitive functioning,
- ability to maintain attention (e.g., to a video monitor),
- ability to sit in front of a camera and minimize extraneous movements to avoid compromising the image resolution,
- willingness of the client/patient and family/caregiver (as appropriate) to receive services via telepractice;
- communication characteristics, including
- auditory comprehension,
- speech intelligibility,
- cultural/linguistic variables,
- availability of an interpreter;
- client's/patient's support resources, including
- availability of technology,
- access to and availability of resources (e.g., telecommunications network, facilitator),
- appropriate environment for telepractice (e.g., quiet room with minimal distractions),
- ability of the client/patient, caregiver, and/or facilitator to follow directions to operate and troubleshoot telepractice technology and transmission.
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).
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.
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
- aural rehabilitation (Polovoy, 2009; Yates & Campbell, 2005)
- cochlear implant fitting (Wasowski et al., 2012)
- hearing aid fitting (Campos & Ferrari, 2012)
- infant and pediatric hearing screenings (Krumm, Huffman, Dick, & Klich, 2007; Krumm, Ribera, & Schmiedge, 2005; Lancaster, Krumm, Ribera, & Klich, 2008)
- pure tone audiometry (Krumm, Ribera, & Klich, 2007)
- speech in noise testing (Ribera, 2005)
- videootoscopy (Burgess et al.,1999; Eikelboom, Atlas, Mbao, & Gallop, 2002; Heneghan, Sclafani, Stern, & Ginsburg, 1999; Sullivan, 1997).
Telepractice is being used in the assessment and treatment of a wide range of speech and language disorders, including
- articulation disorders (Waite, Cahill, Theodoros, Busuttin, & Russell, 2006; Crutchley, Dudley, & Campbell, 2010)
- autism (Parmanto, Pulantara, Schutte, Saptono, & McCue, 2013)
- dysarthria (Hill et al., 2006)
- fluency disoders (Carey, O'Brian, Onslow, Packman, & Menzies, 2012; Lewis, Packman, Onslow, Simpson, & Jones, 2008)
- language and cognitive disorders (Brennan, Georgeadis, Baron, & Barker, 2004; Waite, Theodoros, Russell, & Cahill, 2010)
- dysphagia(Malandraki, McCullough, He, McWeeny, & Perlman, 2011; Perlman & Witthawaskul, 2002)
- voice disorders (Halpern et al., 2012, Mashima et al., 2003; Theodoros et al., 2006; Tindall, Huebner, Stemple, & Kleinert, 2008; Towey, 2012).
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
- ensure that telepractice clinicians (who may not reside in the state where the school is located) meet all state requirements to practice in the school,
- make certain that telepractice clinicians have knowledge, skills, and training in the use of telepractice,
- recognize that every student may not be best served by a telepractice model and give students the opportunity to receive traditional in-person services,
- inform parents that they have the right to decline telepractice services for their child,
- provide parents with an informed consent, satisfaction survey, or other feedback option and opportunities to discuss concerns about their child's progress or the telepractice program,
- document service delivery via telepractice on the Individualized Education Plan (IEP) and during the IEP meeting,
- formulate policies that ensure protection of privacy during the services as well as documentation of the services,
- provide on-site support for the telepractice sessions, including the assignment of an individual to accompany the student to the session and provide support during the session,
- develop a plan for inservicing staff, training on-site facilitators, and maintaining ongoing contact and collaboration with teachers, parents, and other school personnel-thereby ensuring that state standards are met,
- develop a system of program evaluation to measure the effectiveness of the service and satisfaction of stakeholders.
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
- camera capabilities (e.g., pan-tilt-zoom [PTZ] and resolution), display monitor capabilities (e.g., size, resolution, and dual display), microphone and speaker quality, and multisite capability;
- peripheral devices, such as recording devices or auxiliary video input equipment for computer interfacing, document cameras, or other specialized cameras with high resolution (e.g., fiberoptic videoendoscopes);
- additional modes of real-time interaction through applications such as screen sharing, whiteboards, online presentations, or text chat.
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
- Network connection speed impacts overall quality of video and audio clarity. A review of 225 articles on videoconferencing in clinical contexts, including speech-language pathology, revealed that a minimum bandwidth of 384 Kbps was needed to establish adequate audio and visual clarity (Jarvis-Selinger et al., 2008).
- Available bandwidth may be reduced by the number of users on the communication network-for example, during peak usage times in schools.
- Higher connection speeds may be required for high definition (HD), dual-streaming video presentation, or hosting multipoint calls. Lower bandwidth may result in delays, jitter, and loss of data and may interfere with quality of signals for clinical decision making or normal turn taking in conversational discourse.
- Establishing an alternative connection (e.g., telephone, e-mail) enables participants to troubleshoot connection problems or to reschedule the session.
- Lack of technological compatibility may be a barrier to connecting sites with different hardware, software, and bandwidth speeds. A financial investment may be required to upgrade the infrastructure to ensure the interoperability of equipment at all participating sites.
- Secure transmission during telepractice may be obtained through the use of encryption, unique passwords, unique meeting numbers, secure connection via virtual private network (VPN), and hardware/software firewalls.
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.
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
- state and federal regulations pertaining to electronic storage of consumer information for local computer servers and local area networks, servers shared by wide area networks, and servers accessible by Internet users;
- types of technologies with privacy protections, including new or evolving forms of software and hardware solutions to ensure consumer privacy (e.g., encryption, virtual private networks [VPN], firewalls);
- the need for telepractice software and hardware applications to be configured for use with encryption, VPN, or firewall applications;
- applications of VPN software, including downloading and configuring VPN software for modem, backbone, and satellite connections;
- principles for training support and professional personnel concerning appropriate local standards for privacy of health care information of consumers;
- breach notification policy.
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
- adding telepractice to the organization's strategic plan to ensure administrative support and allocation of resources;
- integrating telepractice program needs into existing organizational processes, personnel networks, and training activities;
- conducting pre-implementation planning with technical support staff to troubleshoot firewall and bandwidth issues;
- learning about and advocating for reimbursement mechanisms to sustain telepractice programs;
- educating staff on roles and responsibilities and the organization's plan for provider training, quality assurance, provider and client/caregiver/student/parent satisfaction, and ongoing program development;
- conducting outreach to the community, including satisfaction surveys.