| Gregg Givens tests the auditory thresholds of a woman, shown on the monitor, at a remote site via the Internet.
Audiology telepractice-the application of telecommunications technology to delivery of audiological services at a distance-is here. Technological advances have brought us the equipment and infrastructure to assess the auditory system from a remote site. However, professionals who wish to engage in audiology telepractice have many issues to consider in the development of a telepractice, such as the goals of the practice, infrastructure, paraprofessionals, patient privacy, licensure, ethics, and reimbursement.
The goal of one's practice should always dictate the structure. This is certainly true in telepractice. Audiology telepractice can take several forms. A common practice is the store-and-forward of audiometric data. In this form, data are collected at a remote site and are then forwarded via electronic means, such as telephone lines, Internet, or e-mail. This form of audiology telepractice is currently being used with data such as auditory brainstem response and otoacoustic emissions (OAE) recordings.
Another form of audiology telepractice is synchronous communication in which real-time data are collected from a remote site, usually through video and audio contact between the sites. Current applications of synchronous communication in audiology are audiometric threshold assessment (Givens et al., 2003; Givens & Elangovan, 2003), and video-otoscopy (Eikelboom et al., 2002).
The issue of infrastructure is one that cannot be ignored in audiology telepractice. The communication network infrastructure between the audiologist and patient dictates what type of program can be developed. Synchronous communications require an advanced telecommunications network, such as access to the NGI (next generation Internet) which would create a broad avenue of information flow between the two sites. However, this advanced technology is not available in most cases where remote assessment is needed. Some audiology telepractice programs are based on less advanced technology, such as dial-up Internet access or video telephone technology. This less advanced infrastructure has been shown to be appropriate for some telepractice applications, such as hearing tests performed as part of rural early hearing detection and intervention programs (Krumm, in press). Thus available network infrastructure and reliability are critical in planning a tele-audiometry program.
Other issues that must be considered before patient contact can occur include: availability of paraprofessionals or other allied health professionals at the remote sites, patient confidentiality, equipment calibration, licensure in the geographic area of the patient, liability, reimbursement, and professional ethics. Policies regarding patient privacy and reimbursement have been addressed in medical disciplines such as cardiology, dermatology, and otolaryngology.
Licensure has been addressed by the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology (NCSB). A recent 2003 NCSB Position Paper, which proposed a model approach for licensure boards, noted: "Although there is not a uniform practice act, and standards do vary from state to state, licensure boards nonetheless share the responsibility to protect consumers regardless of the mode of service delivery. The establishment of telepractice regulations will not only protect the consumer, but lessen previously existing barriers to health care." Issues such as licensure, liability, reimbursement, ethics, client eligibility and outcomes, and knowledge and skills for clinicians are also addressed in ASHA's new practice policy document "Audiologists Providing Clinical Services via Telepractice," which was approved in March 2004.
In 2002, ASHA surveyed audiologists to assess the experiences that are ongoing in the area of tele-audiology. Twelve percent of the audiologists indicated that they were using some form of telepractice, with the most common service being counseling via telephone. This illustrates the infancy regarding the application of telecommunication to our profession.
There are a few audiology telepractice programs that are currently providing direct patient care. Most programs are in the form of clinical feasibility study. Programs at Utah State University, Minot State University, and East Carolina University are examining the feasibility and clinical outcomes of audiometric threshold assessment, applications of the HINT (Hearing In Noise Test), measurement of OAE and auditory evoked potentials. The University of Hawaii has demonstrated the successful application of a system that provides Web-based education and clinical services in hearing and vestibular assessment. Although these programs are making strides, there remains a need for controlled data-based clinical outcome studies demonstrating the validity and reliability of these remote applications to audiology.
The current state-of-the-art in audiology telepractice highlights the need for study and developments on several fronts:
- Research regarding clinical outcomes of these remote measurements in an effort to develop valid and reliable clinical protocols
- Continued application of developing technology and infrastructure to audiology
- Advocacy efforts in the area of reimbursement
- Development of national guidelines in licensure for this area and/or the development of interstate licensure compacts such as the one initiated by the Interstate College of Nursing
A Few More Words
The promise of reaching underserved populations motivates many of the professionals in this area. I personally believe we have a moral and ethical responsibility to put efforts toward the development of tele-audiology in the hope of reaching a goal of better global hearing health. We at East Carolina University are working toward this goal and welcome others to join in. The technology is here; the only thing that can stop us is lack of imagination.