At Tripler Army Medical Center (TAMC) in Honolulu we are investigating the remote delivery of speech-language pathology services to patients who traditionally were air evacuated from Japan to Hawaii for voice treatment. Telepractice is enabling us to overcome the challenges of our geographic distance and the unavailability of speech-language pathologists at remote military medical facilities.
Over an 18-month period in 2000 to 2002, military otolaryngologists in the Pacific Rim referred 26 patients with voice disorders to TAMC. These patients were generally seen for a condensed two-week course of treatment that compromised treatment outcomes and incurred significant cost in terms of travel expenses and time away from their duty stations. The use of telecommunications technology would allow our patients from Japan to receive the standard course of treatment.
In order to eliminate connectivity issues and validate our treatment protocol for remote delivery, we conducted an in-house proof-of-concept investigation. This study evaluated treatment outcomes for a vocal rehabilitation protocol delivered with the patient and clinician interacting in the same room (control group) and with the patient in one room and the clinician in an adjacent room interacting in real time via a hard-wired video camera and monitor (telepractice group). Fifty-one participants with voice disorders completed the protocol. There were no significant differences in perceptual, acoustic, patient satisfaction, and fiberoptic laryngoscopy ratings between the control and telepractice groups.
Participants in both groups showed positive changes on all four outcome measures after completing voice treatment. In addition, we received favorable responses from patients regarding their experience and comfort with using technology to receive services. We are currently validating our in-house data with deployment of remote video teleconferencing (VTC) units to a satellite clinic in rural Oahu and a military hospital in Japan.
Our project is funded by the Pacific Telehealth and Technology Hui, which is a joint venture between the Department of Defense and Department of Veterans Affairs to improve the quality, accessibility, patient satisfaction, and cost-effectiveness of health care services provided to beneficiaries through the use of emerging and existing telepractice technologies. Our co-investigators from the University of Hawaii Telepractice Research Institute are Lawrence Burgess, otolaryngologist, and Deborah Birkmire-Peters, research psychologist. Deploying our telepractice application not only requires us to investigate technological acceptability and effectiveness issues, but also to integrate our application into a health care system that crosses institutions as well as geographic boundaries and time zones.
To facilitate successful deployment, our goal has been to integrate our services as seamlessly as possible into the operations of both sites, including routine clinical and administrative functions. To this end, having an on-site coordinator for our project has been crucial. Prior to installing equipment and initiating our services, it was necessary to establish a collaborative relationship with the referring hospital in Japan, including laying the groundwork with administrative agreements. Otolaryngologists LT Douglas Miller and LT Dimitry Goufman, and SLP Julia Notarianni have served as our co-investigators and telepractice "champions" at our remote site in Japan.
The first step in developing our clinical protocol was to select the modality best suited for our application. We elected to use the synchronous model of delivery rather than asynchronous because real-time interaction is critical to conducting treatment. Our next step was to select appropriate telepractice technologies including software, equipment, and peripheral devices to support our clinical procedures. A factor that affected our selection was the existing infrastructure to provide connectivity with the preferred technology. Technical assistance from an IT systems engineer was essential in configuring components to deliver our protocol, which involved interfacing voice analysis with teleconferencing software and hardware, and ensuring their interoperability. Verification of adequate bandwidth to enable accurate diagnosis and effective treatment was accomplished through consultations with telecommunications specialists and simulations with colleagues.
We are using video teleconferencing systems connected via Integrated Services Digital Network (ISDN) lines with 384K bandwidth. Our video monitor is a 20" TV-VCR combo that provides the capability of recording our sessions and viewing instructional videos with patients. Software interfaced with the VTC system and a desktop computer enables us to record and analyze voice samples. In the Otolaryngology Clinic, laryngeal exams are performed with a digital videostroboscopy system. Data files that include recordings of voice samples and laryngeal images are captured, saved, stored, downloaded, and reviewed remotely.
Prior to our initial session, patients are reassured that their privacy and confidentiality will be protected with our built-in security system and that the quality of care should not be compromised as evidenced by our in-house proof-of-concept study. Our VTC calls are typically initiated 15 to 30 minutes prior to each session to perform equipment checks and troubleshoot connectivity problems as necessary. Having point-of-contact information or telephone numbers for both sites is critical when we experience connection failures. We establish and follow a routine in treatment to provide a familiar structure to each session. Written handouts are used to enhance learning. We have found that patients who initially were apprehensive about being able to hear and understand the clinician over the VTC system seemed reassured with hard copies of written materials and diagrams. These materials are transmitted by fax or as e-mail attachments and may be used for home practice.
Although the goal of telepractice applications has been to ensure at least the current standard of care, our objective is to improve the quality of care with the integration of technology into our practice. For example, rather than using analog audiotape recorders and videotape recorders we are using computers and software to capture, store, and transmit digitized recordings of voice samples and laryngeal exams. This technology is readily available and applicable to support our routine clinical procedures. Digital files provide efficient access and superior quality for perceptual ratings. In addition, we record target voice samples from our treatment sessions and exercises for home practice on compact discs rather than audiotapes since this is the medium that is commonly used by our patients.
A Business Case
Lack of funding to establish and maintain telepractice services has been cited as a barrier to fulfilling the potential of integrating technology into health care. While it is imperative to prove clinical effectiveness and efficacy and validate remote delivery of our services, it is also important to build a business case for telepractice with demonstration of cost savings, cost avoidance, or potential income that exceeds start-up and maintenance costs. We submitted our in-house proof-of-concept and deployment protocols to grant competitions for funding. In addition we received approval from our institutional review board to conduct our study. To support reimbursement for telepractice services we must be able to document desirable clinical outcomes and cost effectiveness through empirical studies. Once telepractice services are established, utilization is critical to ensure profitability and sustainability.
Multi-use of the VTC system for distance learning, professional development, administrative conferencing, and partnering with organizations could be included as a benefit in the business case. In addition to resolving personnel shortages or disparities between rural and metropolitan areas, telepractice provides the capability of consulting with subspecialists on challenging cases and continuing education opportunities for clinicians. Telepractice also affords the possibility of establishing statewide alliances or a network of providers to merge resources and professional expertise. Within such a network, clinicians could be mentored in subspecialties and caseloads could be covered on a temporary basis in the event of provider absences. Consortiums could be formed to share the cost of establishing and maintaining a telepractice system.
Telepractice has considerable potential and relevance to speech-language pathology. In addition to improving accessibility to and increasing availability of care, telepractice enables us to deliver care in the least restrictive environment, increase participation of family members in the clinical process, and increase efficiency in delivering services, particularly for itinerant clinicians. With decreasing costs of telecommunications technologies and devices, more widespread connectivity, increasing demand for home health care, personnel shortages, and increasing acceptance and satisfaction on the part of clinicians and patients, the future of telepractice in our profession is promising.
The views expressed in this article are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.