Telepractice or telepractice-the provision of health services from one location to another using a telecommunications medium-is becoming ubiquitous as many states have developed wide area networks (WANs) that connect rural and metropolitan communities.
Most hospitals focusing on rural outreach provide health services via telepractice using dedicated WANs or the Internet. Professions engaged with telepractice include speech-language pathology, nursing, cardiology, radiography, otology, pharmacology, psychology, psychiatry, and dermatology (Nickelson, 2000; Perednia & Allen, 1996; Stamm, 1998). Telepractice services that health care professionals may provide include video otoscopy, counseling and diagnosis with interactive video, cognitive retraining, radiology interpretation, surgery via robotics, and bioterrorism monitoring.
Although audiologists have been slow to adopt telepractice, there are compelling reasons to use this medium. Specifically, audiology telepractice may offer a solution for service gaps in rural or underserved urban areas. Using telepractice, audiologists in regional clinics could offer sophisticated hearing tests to infants, children, and adults in rural communities. Aural rehabilitation, digital hearing aid programming, and cochlear implant programming or mapping also could be achieved through telepractice technology with few software modifications.
An effective audiology telepractice program could further promote a family-friendly atmosphere as well as continuity of services for people of all ages (Krumm, Ribera, & Schmiedge, 2005). Specifically, telepractice technology could provide a link between the records at client medical homes and clinicians providing hearing health care services from a distant location. Information that could be shared via telepractice includes relevant case history information, scheduling, client treatment plans, and the professionals responsible for service delivery. In response to the potential benefits of telepractice, ASHA recently developed a position paper that supports the use of telepractice by audiologists (ASHA, 2004a, b).
State of Practice
The benefits of telepractice are very real, but many issues central to audiology telepractice need to be resolved. Issues such as connectivity, accessibility to telepractice systems, convergence of technology, and clinician acceptance illustrate the current state of practice-and the challenges that remain.
Connectivity. The primary considerations of connectivity include bandwidth capability and the information transmission medium (such as cable, digital subscriber lines, or modem). Broadband connections provide the capacity to transmit the most data in the least amount of time. Not surprisingly, broadband is the gold standard in the world of telemedicine.
Recently, investigators at the American Telehealth Association (ATA) annual meeting described the use of portable satellite technology. This is the same technology that many television networks use to broadcast events from locations around the world. Although satellite technology is not new to telemedicine, the use of portable satellite technology is an important advancement that opens doors to virtually any geographic location.
While satellite technology has historically provided slower connectivity speeds than other forms of broadband (due to the long distance that transmitted information must travel), portable satellite technology can still be used for interactive video and other "live" telepractice services. Therefore, at least limited telepractice services can be delivered to rural communities that do not have broadband infrastructure.
Connectivity innovations are not limited to the satellite technology. Kent State University developers have created a wireless Internet system that includes a portable power source. This system can be used in rural communities without basic power services. Although wireless technology has bandwidth restrictions and is occasionally unstable, the Kent State University wireless Internet can provide a telepractice link in rural areas at less expense than portable satellite technology. Finally, even though the Kent State portable Internet system is ultimately dependent on a regional wireless system, in most situations this is a viable option.
Accessibility of telepractice technology. The greatest gains in connectivity are related to accessibility. Even the most rural communities in the United States often have broadband capacity through commercial satellite or cable Internet services and these services are developing even a greater presence in rural areas as costs drop and quality improves. Further, many states have intentionally created powerful Internet capacity at most rural schools, government offices, colleges, and medical clinics. This provides a gateway for clinicians to provide telepractice services to these facilities using high-quality technology. In some cases the rural communities have state-of-the-art telepractice suites including high-quality interactive video equipment and exceptional bandwidth capabilities. Access to these facilities is often granted to clinicians by state or local telepractice administrators and a fee for use is commonly required. This fee provides greater quality and privacy and serves as a cost-efficient solution for providing face-to-face services in distant rural areas.
Convergence of technology. In the past year, surprising hardware and software solutions were possible due to dramatic changes in software capacity. Inexpensive Web cameras marketed primarily to home users were coupled to cost-effective high quality interactive video software. Clinicians are now able to experience high resolution interactive video conferencing with clients at a fraction of the cost required two or three years ago. Manufacturers have developed software that meets the needs of telepractice. For example, one manufacturer has provided an encryption program that is seamlessly embedded in interactive video to comply with the Health Insurance Portability and Accountability Act (HIPAA). Quality interactive video software applications now cost less than $150 per site, but still require the latest generation of computer hardware. Nevertheless, conducting telepractice sessions from an office computer is possible today.
Clinician acceptance. Audiologists may find that audiology hardware provides one of the most interesting forms of technology convergence for telepractice. Many new audiology products are Microsoft Windows-based and can be readily integrated for use in telepractice service delivery. Specifically, virtually all digital hearing aids and cochlear implants are programmed through a Windows environment. In addition to amplification devices, diagnostic audiology equipment, real ear, and vestibular systems are often computerized. Because these systems are Windows compatible, they can be interfaced to network and be controlled through application-sharing software for live (or synchronous) hearing assessment. These systems also could be used for store and forward (asynchronous) technology to complement synchronous audiology telepractice services. Either way, the new generation of audiology Windows-based hardware provides a potent, but familiar, platform in which audiology telepractice services can be rendered.
A good example of technology innovation was described by Givens and Elangovan (2003) of East Carolina University (ECU). Specifically, these investigators validated the use of a portable audiometer that was connected to a computer network via the ECU interface technology. This system was supported by custom computer software developed at ECU and was designed specifically for telepractice applications. Preliminary data obtained by Givens and Elangovan indicated that the ECU audiometric system was an accurate tool for measuring hearing thresholds using a telepractice medium.
Successful telepractice services may also be rendered using off-the-shelf software and computerized hardware already available in many clinics. Krumm, Ribera, and Schiedge (2005) described a project to provide telepractice services to infants using equipment designed solely for infant hearing screening. Using off-the-shelf audiology hardware and interactive video equipment, these investigators were able to provide synchronous audiology services to infants 100 miles away. These services included otoacoustic emissions and auditory brainstem response recordings. In addition, Krumm et al. incorporated store and forward technology (using a scanner and e-mail) to receive video otoscopy and immittance results. While the outcomes of this project are not certain, preliminary data comparisons suggest good agreement between face-to-face measurements and data obtained through telepractice technology.
Barriers to telepractice. One of the greatest barriers to audiology telepractice service delivery is cost for equipment, technical support, and software purchases. Commercial audiometers capable of telepractice applications will cost approximately $5,500-$25,000 depending on the system purchased. In addition, a sound booth will be required if diagnostic audiology (rather than screening applications) are anticipated.
Sources for reimbursement of services also must be identified early in the planning stages of audiology telepractice. Not all insurance companies will reimburse for telepractice services and do not uniformly compensate for store and forward services. However, contracts with educational systems or government agencies may provide a basis for reimbursement.
Licensure and liability issues need to be examined in the early stages of telepractice as well. Practitioners will likely have to be licensed in all states to which they are providing telepractice services. Licensure boards for many states do not have policies regarding telepractice and specific assurances in these circumstances must be obtained before services are administered. Also, risk management must be assessed and proper insurance to cover telepractice activities must be secured. A significant component of any telepractice program is HIPAA-compliant procedures to ensure confidentiality of client information.
From Theory to Treatment
There is little doubt that at least some clinicians are seeing audiology telepractice as a means to provide better hearing health services to rural communities. The U.S. military is presently investigating mechanisms to provide Internet-based mapping services to dependents with cochlear implants. Deborah Ferrrari of São Paulo University in Brazil intends to provide hearing tests to isolated communities, including those in the Amazon River region. The likelihood of success is high for both projects due to appropriate funding levels, thoughtful planning, and the accessibility of telepractice technology. Telepractice is finally becoming a realistic tool for clinical applications.