Telepractice

Roles and Responsibilities

Telepractice is an appropriate model of service delivery for audiologists and SLPs.

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 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 about and compliant with existing rules and regulations regarding telepractice, including security and privacy protections, reimbursement for services, and licensure, liability, and malpractice concerns; and
  • collaborating with physicians and other practitioners for timely referral and follow-up services.

Telepractice is constantly evolving. Ongoing education and training is required to maintain expertise and familiarity with changes in technology and potential clinical applications. Web technology allows clinicians to engage clients through virtual environments and other personally salient activities (Towey, 2012a).

Ethical Considerations

ASHA requires that individuals who provide telepractice abide by the ASHA Code of Ethics (ASHA, 2016a), including the following specific principles denoted within:

  • Principle of Ethics II, Rule A: Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience. 
  • Principle of Ethics I, Rule N: Individuals who hold the Certificate of Clinical Competence shall not provide clinical services solely by correspondence, but may provide services via telepractice consistent with professional standards and state and federal regulations.
  • Principle of Ethics IV, Rule R: Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research.
  • Principle of Ethics I, Rule K: Individuals who hold the Certificate of Clinical Competence shall evaluate the effectiveness of services provided, technology employed, and products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected.
  • Principle of Ethics II, Rule G: Individuals shall make use of technology and instrumentation consistent with accepted professional guidelines in their areas of practice. When such technology is not available, an appropriate referral may be made. 
  • Principle of Ethics II, Rule H:  Individuals shall ensure that all technology and instrumentation used to provide services or to conduct research and scholarly activities are in proper working order and are properly calibrated. 
  • Principle of Ethics I, Rule M: Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.
  • Principle of Ethics II, Rule F: Individuals in administrative or supervisory roles shall not require or permit their professional staff to provide services or conduct clinical activities that compromise the staff member's independent and objective professional judgment.
  • Principle of Ethics IV, Rule B: Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative mandate, referral source, or prescription prevents keeping the welfare of persons served paramount.

Licensure and Teacher Certification

A growing number of states have legal or regulatory requirements regarding telepractice. See ASHA’s resource on state telepractice requirements. Prior to initiating services, clinicians should verify state licensure requirements and policies regarding telepractice—including temporary location changes such as vacations and college attendance—in the state from which the clinician provides services and the state in which the client receives services.

Current guidance in medical and legal practices indicates that the client’s location determines the site of service. As a result, a telepractitioner must be licensed both in his or her home state and in the state in which the client resides. Recognizing that this can be a burden to practitioners and a barrier to the growth of telehealth, several professional health care organizations (e.g., nursing, physicians, and physical therapists) are in the process of developing licensure compacts that would facilitate a streamlined process to practice in other states. ASHA currently is supporting an initiative to explore a similar solution for audiologists and SLPs.

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.

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 (in that state) whether licensure or teacher certification—or both—are required. Private contractors or clinicians working for telepractice companies that are contracting in schools would have to have a state license.

International Considerations

ASHA-certified audiologists and speech-language pathologists who deliver telepractice services to individuals in other countries are bound by ASHA’s Code of Ethics (ASHA, 2016a), Scope of Practice in Audiology (ASHA, 2004b), Scope of Practice in Speech-Language Pathology (ASHA, 2016b), Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006), and Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 2004a).

Prior to providing international telepractice services, it is important to

Many possible international telepractice scenarios exist, such as treating American citizens who live abroad or on military bases or providing services to citizens of other countries. ASHA recommends that practitioners check their professional liability status and consult with the regulatory body in that country.

Reimbursement

Telepractice providers should be prepared to educate payers about how telepractice services are delivered and the benefits to clients and payers. Educational materials may include research articles, organization policies and procedures to ensure provider training and quality services, educational/informed consent materials for clients, video clips, and testimonials.

Private Health Insurance

Some states have passed insurance/parity laws (i.e., legislation mandating coverage of telepractice). Generally, the mandates require health insurers 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 and state regulations, if available.  See ASHA State-by-State for more information.  

Medicare

Medicare reimburses some providers for specific telepractice services under specified conditions, but audiologists, SLPs, 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 SLPs, among others.

Beneficiaries can receive covered services only from enrolled providers and may not pay for telepractice services privately.

Medicaid

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; and
  • sets the rate of payment for services.

Practitioners should contact the appropriate state Medicaid office to verify how a telepractice service should be reflected in the billing code and documentation.  See ASHA State-by-State for more information.

Client Selection

Because clinical services are based on the unique needs of each individual client, telepractice may not be appropriate in all circumstances or for all clients. Candidacy for receiving services via telepractice should be assessed prior to initiating services. The client’s culture, education level, age, 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 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); and
    • 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; and
    • willingness of the client and family/caregiver (as appropriate) to receive services via telepractice.
  • Communication characteristics, including
    • auditory comprehension;
    • literacy;
    • speech intelligibility;
    • cultural/linguistic variables; and
    • availability of an interpreter.
  • Client’s support resources, including
    • availability of technology;
    • access to and availability of resources (e.g., computer, adequate bandwidth, facilitator);
    • appropriate environment for telepractice (e.g., quiet room with minimal distractions); and
    • ability of the client, caregiver, and/or facilitator to follow directions to operate and troubleshoot telepractice technology and transmission.

Environmental Considerations

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

Advance planning and preparation is needed for optimal positioning of the client, test materials 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, telepractitioners frequently use computer peripherals—such as audiometers, hearing aid systems, and auditory brainstem response (ABR), otoacoustic emissions (OAEs), and immittance testing equipment—that can be interfaced to existing telepractice networks. Manufacturers are now promoting equipment with synchronous or store-and-forward capabilities.

Teleaudiology is being used in the following practice areas:

  • Aural rehabilitation (Polovoy, 2009; Saunders & Chisolm, 2015; Yates & Campbell, 2005)
  • Cochlear implant fitting (Hughes et al., 2012; Wasowski et al., 2012)
  • Hearing aid fitting (Campos & Ferrari, 2012; Penteado, de Lima Ramos, Battistella, Marone, & Bento, 2012)
  • Infant and pediatric hearing screenings (Botasso, Sanches, Bento, & Samelli, 2015; Krumm, Huffman, Dick, & Klich, 2007; Krumm, Ribera, & Schmiedge, 2005; Lancaster, Krumm, Ribera, & Klich, 2008; Skarzyński et al., 2016; Stuart, 2016)
  • Pure-tone audiometry (Krumm, Ribera, & Klich, 2007; Masalski, & Kręcicki, 2013; Swanepoel, Mngemane, Molemong, Mkwanazi, & Tutshini, 2010; Visagie, Swanepoel, & Eikelboom, 2015)
  • Speech-in-noise testing (Ribera, 2005)
  • Video otoscopy (Biagio, Swanepoel, Adeyemo, Hall & Vinck, 2013; Eikelboom, Atlas, Mbao, & Gallop, 2002)

Speech-Language Pathology

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

  • Aphasia (Macoir, Martel Sauvageau, Boissy, Tousignant, & Tousignant, 2017)
  • Articulation disorders (Crutchley, Dudley, & Campbell, 2010; Grogan-Johnson et al., 2013)
  • Autism (Higgins, Luczynski, Carroll, Fisher, & Mudford, 2017; Iacono et al., 2016; Parmanto, Pulantara, Schutte, Saptono, & McCue, 2013)
  • Dysarthria (Hill et al., 2006)
  • Dysphagia (Cassel, 2016; Malandraki, McCullough, He, McWeeny, & Perlman, 2011; Perlman & Witthawaskul, 2002)
  • Fluency disorders (Carey, O’Brian, Lowe, & Onslow, 2014; Carey, O’Brian, Onslow, Packman, & Menzies, 2012; Lewis, Packman, Onslow, Simpson, & Jones, 2008)
  • Language and cognitive disorders (Brennan, Georgeadis, Baron, & Barker, 2004; Sutherland, Hodge, Trembath, Drevensek, & Roberts, 2016; Waite, Theodoros, Russell, & Cahill, 2010)
  • Neurodevelopmental disabilities (Simacek, Dimian, & McComas, 2017)
  • Voice disorders (Halpern et al., 2012; Mashima & Brown, 2011; Theodoros et al., 2006; Tindall, Huebner, Stemple, & Kleinert, 2008; Towey, 2012b)

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 and disorder variables. Assessment and therapy procedures and materials may need to be modified or adapted to accommodate the lack of physical contact with the client. These modifications should be reflected in the interpretation and documentation of the service.

Some publishers of standardized assessments have developed guidance about administration of tests via telepractice or validated assessments for administration via telepractice (e.g., see Pearson’s guidelines on assessment via telepractice). Other researchers have compared the validity of in-person and remote assessment protocols (Sutherland et al., 2016; Taylor, Armfield, Dodrill, & Smith, 2014).

School Setting Considerations

Schools are currently the most common setting in which telepractice services are delivered. This is due to a number of factors, including shortages of clinicians in some school districts, distances between schools in rural areas, and opportunities to offer greater specialization within a district.

Telepractice services may be provided by private contractors with the local education agency or school district, or the services may be provided by audiologists and SLPs employed by the district. Some states allow reimbursement for eligible students covered by Medicaid when services are delivered via telepractice; however, the state’s Medicaid policy and coding guidance should be verified.  See ASHA State-by-State for more information.

The effectiveness of telepractice as a service delivery model in the schools is well documented (Gabel, Grogan-Johnson, Alvares, Bechstein, & Taylor, 2013; Grogan-Johnson, Alvares, Rowan, & Creaghead, 2010; Grogan-Johnson et al., 2011; Lewis et al., 2008; McCullough, 2001).

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

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 in-servicing 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; and
  • develop a system of program evaluation to measure the effectiveness of the service and satisfaction of the stakeholders.

Telepractice Technology

The use of technology is an inherent element of telepractice. Specifications and selection of the appropriate hardware and software 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 Tools (Hardware, Software, and Peripheral Devices)

Video communication can be accomplished through the use of personal videophones, videoconferencing software, and dedicated videoconferencing hardware and secure web-based programs.

Factors/options in the selection of videoconferencing tools include the following:

  • 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 include (but are not limited to)
    • screen sharing;
    • annotation;
    • whiteboards;
    • online presentation without limitations;
    • text chat;
    • recording (with or without editing capability);
    • touch screen; and
    • interactivity features (e.g., animations, widgets, games, stamps, and paintbrush).

Considerations in Selecting a Web-Conferencing Collaboration Service

There are three web-conferencing option levels—business class, software-based, and public domain.

  • Business class—involves the purchase of hardware and is typically used at large facilities such as universities or medical centers.
  • Software-based—provides information on the level of encryption and includes an agreement with the practitioner on how the client’s information is protected.
  • Public domain—is not validated as secure and often does not indicate how information is encrypted (e.g., Facetime, Skype, and Google Handouts).

When selecting a web-conferencing option,

  • review full product description, subscription details, and pricing;
  • note the required processing speed and needed storage capacity of the personal device to be used;
  • evaluate the ease of use to (a) host an encounter and (b) join an encounter (e.g., required web browser to join meeting or software download);
  • request a trial period to experience features, functionality, limitations, and challenges;
  • consider scalability (number of hosts and attendees permitted);
  • research the responsiveness of tech support and active user communities;
  • determine whether there is an international limitation if dial-in numbers are needed to join the encounter; and
  • review privacy/security features and, if applicable, determine HIPAA compliance.

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 an appropriate connection strategy:

  • Network connection speed affects overall quality of video and audio clarity. Expert users note that an upload/download speed of no less than 3 MB is needed for optimal connection and screen sharing. When adding a shared video source (e.g., Microsoft PowerPoint, YouTube, or video recordings), upload and download speeds should be no less than 5 MB.
  • 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 a high-definition (HD), dual-streaming video presentation or for 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 hard-wired connection is optimal in a shared Wi-Fi environment.
  • 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.

Facilitators in Telepractice for Audiology and Speech-Language Services

Appropriately trained individuals may be present at the remote site to assist the client.  Unless restricted by institutional or state policies or regulations, the facilitator may be a teacher’s aide, nursing assistant, student clinician, audiology assistant or speech-language pathology assistant, teleaudiology clinical technician, telepresenter or other type of support personnel, interpreter, family member or caregiver, among others. Practitioners must be aware of applicable state policies and regulations regarding the use of facilitators.

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 pracitioner to direct the session and ensure that the facilitator is adequately trained to assist. Adequate training includes knowledge of and sensitivity to clients’ cultural and linguistic differences as well as how such differences may influence participation in telepractice (see ASHA’s Practice Portal pages on Bilingual Service Delivery and Cultural Competence). The hierarchy for preferred interpreters in telepractice is consistent with that used for interpreters during in-person practice (see ASHA’s Practice Portal page on Collaborating With Interpreters).

Privacy and Security

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

Clinicians providing services via telepractice are bound by federal and state regulations as they would be when providing in-person services. The following federal legislation addresses privacy and security for covered entities:

  • Health Insurance Portability and Accountability Act of 1996 (HIPAA; U.S. Department of Health and Human Services, n.d.-b)
  • Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH; U.S. Department of Health and Human Services, n.d.-a)
  • 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 ASHA’s resource on Health Insurance Portability and Accountability Act for general information about HIPAA. See also ASHA’s resources on 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 provider’s policies and how a provider implements a given program helps 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 privacy and confidentiality at both sites. Clients 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. This may include a description of the equipment and services to be delivered, how services via telepractice may differ from services delivered in person, the individual’s right to revert to traditional face-to-face care at any time, any modifications that will be made in assessment protocols, and potential confidentiality issues. Documentation may also include the type(s) of equipment used, the identity of every person present, the location of the client and clinician, and the type and rate of transmission.

It is the clinician’s role to ensure client 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, 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 and satellite connections;
  • principles for training support and professional personnel concerning appropriate local standards for privacy of health care information of consumers; and
  • breach notification policy.

Enlisting Stakeholder Support

When implementing a telepractice program, 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. Without mutual understanding, collaboration, and a receptive attitude toward telepractice on the part of all stakeholders, a telepractice program can fail.

Methods for enlisting support include

  • adding telepractice to the organization’s strategic plan to ensure administrative support and adequate 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; and
  • conducting outreach to the community, including satisfaction surveys.

Employment in Telepractice

Telepractice may be one aspect of an institution’s or company’s services, or it may be the exclusive focus. Because telepractice is a relatively new area of service delivery, audiologists and SLPs have questioned how to determine whether a prospective employer provides appropriate training and support enabling them to deliver high-quality services.

The following are questions that could be explored by a potential telepractitioner:

  • How do the employer’s policies and technology protect client privacy and security?
  • How does the employer support and facilitate communication with other stakeholders outside the therapy session (e.g., teachers, family members, rehab team, IEP meetings)?
  • What features does the employer’s system offer (e.g., camera zoom, picture-in-picture)?
  • Does the employer have business associate agreements, particularly if it shares Protected Health Information (PHI) with third party payers?
  • What training is provided to the clinician, and does the clinician have to demonstrate competencies in the use and knowledge of telepractice that align with ASHA’s guidance?
  • What kind of ongoing technical and clinical support is provided by the employer to the clinician?
  • Who is responsible for the facilitator (e.g., teacher’s aide, audiology assistant or speech-language pathology assistant, other support personnel, or interpreter)?
  • Does the employer have a process for evaluating telepractice sessions to ensure that the quality of service is the same as that provided by in-person service?
  • Does the employer provide malpractice insurance?
  • Does the employer assist with securing additional state licenses if the practice is to be multistate?
  • Does the employer benchmark telepractice outcomes with on-site (traditional) outcomes to ensure equivalent levels of service?

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.