The Urban Perspective
by Jill Georges and Norbert Belz
When the University of Kansas Hospital was asked to become involved in remote, interactive videoswallow evaluations, we saw it as an opportunity to improve services in rural areas. We first reviewed the literature and found that telepractice had been used for a variety of speech-language pathology and audiology services, but the only published report of utilizing telemedicine for videoswallow evaluations was by Perlman and Witthawaskul (2002), who utilized an Internet system for real-time, remote, interactive evaluation of swallowing. Our technology utilized a videoflouroscope that attached directly to a Polycom F/X system at the remote site.
This project was funded by a three-year federal grant from the Office for the Advancement of Telehealth (OAT). The grant helped establish services at the sites in which we conducted the swallow studies. The clinic/hospital provided the fluoroscope and radiology equipment. The original grant covered the telecom monthly costs as well as usage during the evaluation (typically $30-$50/hour), and provided a stipend for our professional time ($75/patient) and for the site coordinator.
We were satisfied that the quality of the videoswallow study would be comparable to one obtained in our own fluoroscopy suite, but were reluctant to become involved unless we were sure that preparation and follow-up would be adequate. We knew that many of our patients would be elderly nursing home residents. We were fortunate that the co-author of this article, Kristy Potter, is a speech-language pathologist (SLP) who was able to complete clinical swallow evaluations, partner with us in completing swallow studies, and provide follow-up.
We also wanted to ensure that our venture was within our scope of practice and licensure laws. ASHA's Code of Ethics (2001) states that individuals may practice telemedicine where not prohibited by law. The National Council of State Boards of Examiners for Speech-Language Pathology and Audiology (NCSB) issued a statement in 2004 that SLPs and audiologists must be licensed in the state in which the service is provided. This limitation was not an obstacle as both sites are in Kansas.
The remote, interactive swallow studies were well received at the remote site. Both clinicians were comfortable with the technology and studies indicated good acceptance by patients. A unique aspect of our experience was the opportunity to have certified SLPs at both sites, greatly enhancing the service we provided. Involving two providers also meant that our purpose evolved from simply providing videoswallows in a remote area to also training the clinician to perform this service independently.
Unfortunately, the grant that funded this project recently expired. In addition, the remote hospital–in a rural town that has been struggling economically–recently closed. The steady number of patients in need of this service must now be transported two hours to receive a videoswallow. We were fortunate to have an experienced radiology technician through most of this project, but he eventually resigned to seek employment opportunities elsewhere. Fortunately, the facility still has a radiology suite available for a future radiologist/technician.
The cooperative venture increased the skill and confidence of the clinician at the local site, who now can complete swallow studies independently, and provided an invaluable diagnostic service to patients in an underserved rural area of Kansas.
The Rural Perspective
by Kristy Potter
After completing graduate school, I accepted a position in a rural, remote area in Kansas. It was 1992, and speech-language pathology services were just emerging in small hospitals and long-term care facilities. Although I knew I was licensed and qualified to diagnose and treat my patients, feeling competent to do so was another story. Yes, I had completed a respected, accredited graduate program; however, instead of feeling confident, I was feeling more of the usual (and may I now say expected) "I'm not quite sure what to do" angst of a brand-new Clinical Fellow.
This feeling was most pronounced in the area of dysphagia. I was exposed to dysphagia in my practicum, but it was limited at best. I had some instruction on diet modification and I watched a few videotaped modified barium swallows (MBS), but I had no first-hand experience establishing and implementing a treatment program for dysphagia. Suddenly, I was the sole resource in several facilities with patients with dysphagia. In our remote area, MBS evaluations were typically not available, so I read what I could and tried to consult with other clinicians. I, however, was one of only a few speech-language pathologists (SLPs) practicing in a rehab setting, and certainly the only one in my facilities. Experience was often the result of trial and error.
The challenges I faced in Kansas were typical of SLPs practicing in rural areas. I spent most of my career providing services to rural and remote facilities without equipment, support staff, or established competence to perform videoswallows. My only assessment tool was a clinical bedside evaluation, which research tells us may miss aspiration 40%-60% of the time (Logemann, 1998; Splaingard, Hutchins, Sulton, & Chaudhuri, 1988). As the use of MBS became more widespread, I began to refer my patients to a hospital that could perform this service. Travel to the hospital imposed great hardships (in my current position, a 100-mile round trip). Three years ago, I was invited to participate in the first remote, interactive telemedicine videoswallow evaluation with the University of Kansas Medical Center (KUMed). Since that time we have routinely utilized telepractice to complete videoswallow evaluations.
Using telepractice, the SLP at KUMed is able to view swallowing evaluations transmitted from our rural site. The videoconferencing device attaches directly to the digital fluoroscope, providing a live, radiologic image that is seen by the SLP at the urban site as effectively as if she were seeing it on the
fluoroscope in her own facility.
Except for the technology involved, our procedures are similar to those used during any videoswallow evaluation. I receive a consult, complete a clinical swallow evaluation, and forward medical information and clinical swallow evaluation results to the clinician at the Center for Telemedicine and Telepractice at KUMed. During the instrumental swallow evaluation, I provide the "hands on" portion of the swallow study. The SLP at KU Hospital is able to converse with me and the radiology technician and observe the patient before the fluoroscopy. Once the swallow study is initiated, the fluoroscope is attached to the Polycom, allowing the SLP to directly observe the study. Meanwhile, she and I are able to discuss the procedure and our observations, and problem-solve as indicated. After the study, we discuss the case and finalize recommendations. I provide follow-up with caregivers and initiate treatment when indicated.
The benefits of telepractice for videoswallow evaluations are many and far-reaching: it provides rural, underserved areas with access to an academic medical center and both patient and provider benefit from the knowledge and expertise of a host of specialized medical professionals.
Patients in rural areas may wait days for an MBS; in most cases, telemedicine can be scheduled the next day. Travel and waiting time at the site are also decreased, thus reducing fatigue and improving accuracy of results. Patient follow-up is also enhanced through timely discussion of results and recommendations. In addition, the interactive nature of the evaluation provides an opportunity for professional growth and skill development. Practicing in a rural environment is often rather isolating with very few opportunities to interact with colleagues. Telepractice offers a way to expand one's knowledge base while developing mentor and peer relationships that would otherwise not be available.