When telehealth technology first became available at our center four years ago, we leapt at the chance to explore its use. Because so many of our clients must travel great distances to get to our center, we saw telehealth as a possible way of improving accessibility and cost-effectiveness of services for some of our clients. In spite of our enthusiasm, we have taken a fairly cautious approach, beginning with clients that we think are the best possible match for the technology, evaluating our results, and expanding our experience one step at a time.
It is an exciting and interesting journey. We continue to discover some unexpected benefits as well as some challenges. In this article, I share some of our experiences and lessons we learned through our venture into telehealth.
What Is Telehealth?
Telehealth is defined in various ways. Drawing on the University of Alberta's Web site, the 2001 ASHA telepractices report defines telehealth as "a means of sharing health information and providing health care services using interactive video, audio, computer, and advanced telecommunications technologies." Telehealth applications can be as complex as transatlantic surgery or as simple as using the plain old telephone system. The most commonly used technology in delivery of clinical services is interactive audio-video (I-AV), also known as video-conferencing or two-way audio-video.
Why Use Telehealth?
Tips for Getting Involved in Telehealth
One of the ongoing challenges our health care system faces is that of uneven distribution of health care services. Because of centralization of many services, large portions of the population are without access to many of the health services that are available to others. Telehealth is one of the fields that arose to address this problem. It holds particular promise in bringing services to remote or rural communities, to people with reduced mobility, and to populations requiring specialist services.
As Mashima and colleagues have pointed out, telehealth has considerable relevance for speech-language pathology because of the increasing need for services, the shortage of personnel in rural areas, and the benefit to clients of having services in their home community. Several speech-language pathology applications of telehealth are described in ASHA publications and in the recent report of the ASHA Telepractices Team. ASHA members are applying telehealth technology to provide training, education, assessment, and intervention. Clinical populations served include those with neurogenic disorders, traumatic brain and spinal cord injuries, dysarthria, head and neck cancer, and disorders of hearing, voice, and fluency.
Telehealth at the Institute for Stuttering Treatment and Research
The Institute for Stuttering Treatment and Research is a non-profit center devoted to stuttering treatment, research, training, public education, and providing treatment in a variety of formats to people of all ages who stutter. It has a worldwide scope, with clients coming from as far as the Middle East and Japan. In fact, roughly 70% of the clients who attend our intensive clinics are from beyond the area of greater Edmonton, Alberta, Canada, where the facility is based.
This poses a special challenge for offering the follow-up services that are important to facilitating maintenance of clinical gains after treatment. Moreover, many people who contact our center are from remote areas where speech-language pathology services are minimal or non-existent. Of the many who request help, only a few are able to travel to Edmonton for treatment; the commitment of time and resources is prohibitive for many.
When telehealth became available in our home faculty of Rehabilitation Medicine, we saw it as a possible means of addressing the problem of accessibility. Given that telehealth is a relatively new modality in our field and not yet researched sufficiently to establish its effectiveness, we have taken a measured approach to ensure we can preserve quality of care. In exploring the use of telehealth, our initial aims are to determine feasibility and clinical practice issues.
We use a variety of room-based systems for our telehealth sessions. Equipment includes a codec (hardware or software that converts analogue signals to digital and then compresses them), two monitors, a camera with remote control, a videorecording unit, two microphones (an omni directional and a wireless microphone), and a document camera. Transmission is primarily through ISDN lines, although switch-56 and satellite connections were used for some sessions.
Case Selection and Clients Served
In the absence of research-based guidelines for determining those cases that are most suitable for telehealth, we developed our own criteria.
Our criteria vary, depending on the clients' ages. For instance, because of the challenge of maintaining the attention and motivation of very young children, we have chosen for telehealth treatment only those preschool children who are suitable for a parent-based intervention like the Lidcombe program, a parent-administered behavioral treatment for early stuttering. For older children and adults, our criteria are based on stuttering severity and responsiveness to treatment probes. Thus far we have been selecting only clients whose stuttering severity is in the mild-moderate range and who have good stimulability.
We have also only considered for telehealth treatment those clients who are unable to come to the clinic or stay long enough to complete the treatment program, have access to telehealth equipment in their home communities, and are receptive to the I-AV technology.
To date, we have conducted more than 80 telehealth sessions with clients ranging in age from 3 to 38. In most cases, clients go to telehealth sites in their community health centers, although some are seen at videoconference centers in their school or workplace. All cases but one were seen through a combination of in-clinic and telehealth visits. Only one case, a 10-year-old with mild stuttering, was seen entirely through telehealth.
As indicated above, treatment of young children was based on the Lidcombe program or other parent-administered approaches. Treatment of older children and adults was based on the Comprehensive Stuttering Program, an integrated approach for the treatment of established stuttering.
Results of our informal evaluation of the use of telehealth in these cases are positive overall. Clinical measures of communicative performance, verbal reports from clients, and clinician judgments all indicate that the treatment goals were met and that the clients were satisfied with telehealth treatment. Although the clients or their families indicated that the telehealth sessions are not the same as face-to-face interactions at the clinic, most of them said they preferred the sessions to traveling to Edmonton and that their savings in cost and time were considerable.
We have learned a great deal through our experiences with telehealth. Lessons learned were in both clinical and technical areas, as well as in adjusting clinical practice to integrate the distance technology.
First, the lack of physical contact was less of a barrier than we initially anticipated. Although it did indeed create some challenges, we were usually able to find solutions. For instance, although we could present pictures and reading material to the child through the document camera or by using the regular camera, we of course could not present manipulable items. Therefore, when we wanted to use games to maintain the child's motivation, we would have the family bring materials from home to the session.
Training parents of preschool children presented another challenge in that we could not use direct modeling to demonstrate the treatment activities with the children. Instead, we had to rely entirely on instruction and give very clear feedback and descriptions of the required adjustments. It also caused us to place even greater emphasis on facilitating parent problem solving. Thus, we found that although the lack of physical contact did place extra demands on the clinician, we were usually able to make adjustments to ensure effectiveness.
We also found that clients generally responded well to the technology and that it did not interfere with the development of rapport. Children tended to adapt very quickly to the system and typically would interact readily with the equipment. Children as young as 4 years old were able to adjust the camera position using a keyboard. Although adults often seemed uncomfortable at first, they tended to adapt to the system within two or three sessions.
Another issue relating to the use of I-AV is the quality of the audio and video information. In telecommunications, the quality of these signals is influenced by the bandwidth, or the amount of information-carrying capacity in a connection. Low bandwidth has a bigger impact on visual information than audio information. Images are less clear and movements cause a tiling effect when bandwidth is low. Audio signals require less bandwidth and therefore are usually unaffected as long as microphone placement and quality are adequate. Because we were connected with a number of different remote sites, we experienced connections that varied in bandwidth from 128 to 384 kilobits per second.
Our impressions are that the integrity of visual information is most important early in the treatment with children, when silent struggle behavior may occur. However, as children progress through treatment and no longer have struggle behavior, the visual information becomes somewhat less important. We therefore were able to work satisfactorily with lower bandwidth transmissions as long as the audio signal was strong. It is likely that different bandwidths are needed for different clinical tasks. This is just one of the many areas that needs to be addressed through research.
Another aspect of signal quality is the transmission time. Many videoconferencing connections are characterized by lag time of up to .5 second. Although we were able to accommodate this to some extent by pausing before responding, we were concerned about the potential effect of the lag on judgments of dysfluencies like subtle silent prolongations at phrase onsets. The delay also affected the immediacy of feedback provided to the client. Although our clinical data suggest that these aspects of signal quality did not interfere with the effectiveness of treatment—the cases where these issues were of possible concern made good progress—nonetheless they are important issues to address in future investigations of telehealth.
In addition to these clinical issues, we also learned some lessons about technological issues. Most room-based telehealth systems are multipurpose and used by a variety of disciplines. Because applications vary, the technical variables that are important for each application also differ. Technical variables that are of significance to our application include the importance of the audio information, synchrony between the audio and video signals, types of microphones, flexibility of camera adjustment on the remote site (to record floor work when necessary), two-way video-recording capability, and availability of a document camera. Fortunately, most of the systems we used could accommodate our particular needs to some extent. However, our experiences highlight the importance of speech-language pathologists having input in the design and selection of equipment and rooms used for tele-speech treatment.
Benefits, Constraints, Conclusions
Overall, we are quite encouraged and stimulated by our experiences with the I-AV technology and believe it will assist us in achieving our goal of increasing accessibility to our treatment. It also has other benefits. It allows for more family involvement in the treatment. It is convenient for clients. And it saves clients the time and money that would be required for travel to the clinic.
Of course, there are constraints as well. One limitation is that I-AV is not suitable for all clients. Research is needed to determine the clients and problems that are amenable to telehealth-based intervention.
Another constraint relates to the costs involved in telehealth. Room-based systems are expensive and require technical support. Transmission costs also are involved. In our case, the clients' health center usually covered the costs as part of their public service. In other cases, the charges were the clients' responsibility. Issues of cost and reimbursement continue to be significant barriers to the use of telehealth.
There also are occasional problems of connectivity that interfere with the treatment. We therefore have to prepare clients for this possibility and have back-up plans in place (e.g., have a telephone in the room). Fortunately for us, problems did not occur frequently and those that did were usually quickly resolved by the technicians.
Access continues to be an issue. Although the technology increases access, there still are limitations. Clients still need to travel to telehealth sites that are few and far between. In our experience, several prospective clients lived too far from the sites to participate. With the development of new videophone and Internet-based technology, these constraints will likely be reduced to some extent. Rapid developments of infrastructure and software mean that practitioners and their clients will soon be able to interact over the Internet in a secure environment. This means that clients will be able to access practitioners right from home.
Finally, telehealth raises a number of legal and professional issues. These include protection of privacy, security, and confidentiality, and standards of informed consent, liability, and licensing. The 2001 ASHA telepractices report provides a summary of some of these concerns. As is true of so many issues in health care, technological developments far outpace our ability to address the ethical and professional issues they raise. Nonetheless, they must be addressed if we are to take advantage of the potential that telehealth offers.
In conclusion, telehealth (and now e-health) is here to stay and offers another tool to advance the accessibility, efficiency, and cost-effectiveness of our work. The expansion of these technologies points to a need to get involved. We need to learn as much as we can about the implications of these technologies on our practice and we need to become active in shaping technology and legislation if we are to create a place for ourselves in the health care systems of the future.