When distance and inaccessibility pose barriers to health care, the answer for some providers is telepractice—and audiologists are no exception. Telepractice brings newborn hearing screening to hospitals in Canada; it shortens the distance families of young children must travel for cochlear implant mapping in Florida; and it helps diagnose medical conditions in Alaska.
According to ASHA's position statement (ASHA, 2005), telepractice (also called telemedicine or telehealth) is an appropriate model of audiology service delivery, provided the quality of services is consistent with the quality of face-to-face services. It offers "the potential to extend clinical services to rural, remote, and underserved populations, and culturally and
linguistically diverse populations."
Telepractice has its advantages—and its disadvantages. Telepractice may save money and time for patients, but delivering service remotely may be more costly than an in-person appointment. Computer connections can result in audio delays or break down completely. Counseling and communication with patients may be compromised.
Audiology telepractice is not widespread. Mark Krumm, associate professor of audiology at Kent State University, attributes low participation to several factors. "Audiology telepractice demonstration projects, which began in the mid-1990s, were successful to various degrees, but few articles were published," he said. "Juried papers have appeared regularly only in the past five years."
The lack of published evidence may have inhibited the growth of audiology telepractice, Krumm said, "and other obstacles may include reimbursement barriers, lack of familiarity with telepractice, and the inability to marshal the necessary resources."
Reimbursement barriers are especially troublesome. The federal Telehealth Act, which includes all health care professional services, stimulated telepractice development. "Oddly enough, however, a U.S. government entity—Medicare—prohibits reimbursement of telepractice services in some health care fields, including audiology," Krumm explained. "Because many insurance companies use Medicare as a guide, reimbursement issues will hamper the development of audiology telepractice until this unfortunate paradox is rectified."
Diagnostic ABRs in Canada
In Canada, audiologists use real-time (synchronous) telepractice to perform diagnostic ABRs on infants in remote communities who do not pass their hearing screenings. "All infants in the province of Ontario receive hearing screening in the hospital or birthing center, and those referred for further testing also receive a screening ABR in or near their own communities," explained William Campbell, Infant Hearing Program (IHP) audiologist and regional IHP coordinator at the Thunder Bay District Health Unit in Ontario.
But the next step—diagnostic ABR—is more difficult to provide. There are 12 IHP regions in Ontario; Campbell's comprises a small population over a large geographic area, including 20 Aboriginal communities reachable only by air. "It's difficult to get infants from the remote areas to a center for a diagnostic assessment," Campbell said, noting that the Canadian health system will transport infants and their families by air for medical care, but not for audiology testing.
IHP is addressing this difficulty by plugging into the Ontario Telemedicine Network, an extensive fiber-optic network that connects almost every remote community in Ontario with medical services. An in-place network, however, is not necessary to perform diagnostic ABRs via telepractice. "Remote ABR testing can be done anywhere by setting up a virtual private network with point-to-point encryption and video conferencing," Campbell said.
The program began earlier this year with one host site (Thunder Bay) and one remote community (Sioux Lookout), and recently added three more remote sites. Campbell expects to have three host sites and up to 15 remote sites operating by the end of the year.
The process requires two information streams—videoconferencing, so the host audiologist can see the infant at the remote site and interact with the technician, infant, and family; and a data stream, on a private and encrypted network, that allows the host audiologist to control the remote ABR equipment.
To perform the diagnostic ABR, Campbell prepares and sends equipment to a technician at the hospital in Sioux Lookout, who then connects the infant with the equipment. Campbell takes control of the remote computer over a secure private network, runs an impedance check, and makes contact with the infant and family. When the infant settles down or falls asleep, he runs the ABR test from the host site. The remote technician needs only minor additional training to facilitate the testing.
Campbell readily admits to some of the program's limitations. "It not a face-to-face assessment," he said. "What do you do if you find hearing loss? It's not appropriate to deliver sensitive news through a remote connection." Social workers are helping to develop a protocol to use when the remote assessment determines hearing loss.
But the benefits far outweigh the obstacles, Campbell said. "We provide access to hearing health care services in remote communities that don't have audiologists and whose residents can't get to an IHP center," he said. "Without diagnostic ABRs via telepractice, there's a huge loss to follow-up of infants referred for further testing."
CI Mapping in Florida
All Children's Hospital in Florida is dedicated to improving accessibility to health care, and maintains 12 outreach centers in addition to its St. Petersburg base. More than 250 patients travel from all parts of Florida and beyond for treatment at its pediatric-only cochlear implant (CI) center.
Many of the hospital's CI candidates come from disadvantaged and nontraditional families, according to Shelly Dolan-Ash, CI coordinator. "Because of difficulties associated with their circumstances—transportation challenges, low education levels, children supervised by several caregivers—the children probably would not be deemed CI candidates by other providers," Dolan-Ash said.
"But when we look at pre-candidacy, we want to ensure the best success possible for each child. If we think that means a cochlear implant, we have a team of audiologists, speech-language pathologists, social workers, and physicians working together to shape the child and family into CI candidates." Bringing CI services closer to the family's home via telepractice is a part of that effort.
Dolan-Ash began offering remote CI mapping to patients at the Sarasota center in March 2007, using a telepractice network that connects the hospital and its outreach centers. Sarasota is only about an hour away, she said, "but those two extra hours of travel make a huge difference" for families dealing with transportation, child care, employment, and other issues.
All CI patients come to St. Petersburg for initial programming and follow-up visits until the child and family are ready for telepractice (the child is attending to and providing conditioned response to sound, the parent is proficient with the equipment, and the CI program is stable).
The sessions with Dolan-Ash in St. Petersburg also help her establish rapport with the family. "I've been in the CI field since 1990," she said. "The most rewarding part is the relationship I develop with the family, which is beneficial to the child's becoming a successful CI user. You have to have that strong foundation in place before going to telepractice, where communication becomes two-dimensional and more stilted."
In remote mapping, an audiologist in Sarasota checks the patient's CI and connects it with the mapping equipment while Dolan-Ash uses videoconferencing to discuss the child's progress with the parents. The Sarasota audiologist readies the child for the conditioned response, and Dolan-Ash sends signals via a remote connection.
The security and privacy of the network are important, Dolan-Ash said, as is the arrangement of cameras and monitors. "You don't want a child distracted by the equipment, but both audiologists need to see the child and each other," she said. The video time lag is also a challenge, and sometimes the entire system "just freezes."
Communication with the family can also be difficult. Dolan-Ash can't see parents' reactions or facial expressions, making it harder to explain what she's doing—and why—during the process.
"Remote CI mapping may be more costly, time-consuming, and difficult," she concluded. "But we are committed to demonstrating its effectiveness and expanding it to more outreach centers so that cochlear implants are a viable option for more children."
Store and Forward in Alaska
In Alaska, secure store-and-forward (asynchronous) telepractice has reduced the amount of time a patient must wait to visit an otolaryngologist (ENT) by more than two months and has reduced patient travel costs by at least $100,000 a year, according to Phil Hofstetter, director of audiology at Norton Sound Health Corporation (NSHC).
NSHC is a nonprofit tribal health consortium serving the health care needs of approximately 10,000 Native Alaskans in 16 communities spread over 44,000 square miles in the Bering Strait region. In addition to its Nome hospital, NSHC operates clinics in 15 Native Alaskan villages.
Before NSHC instituted telepractice in 2001 to consult with ENTs at the Alaska Native Medical Center in Anchorage, patients had great difficulty accessing services. An ENT would come to Nome to see patients "maybe five times a year," Hofstetter said, resulting in appointment waits of up to five months. Getting to Nome for the appointment was also challenging— patients from villages with no road access took a plane trip (paid for by Medicaid or the Indian Health Service), "even for a five-minute ear tube check." Patients needing surgery would have to wait several more months and then fly to Anchorage.
In the telepractice model, the Nome audiologists fly to each NSHC village several times a year. They use a high-definition video otoscope to take images of the tympanic membrane and the structure of the ear. (In some villages, on-site community health aides are trained to collect and transmit the data and images.) The images, along with OAE and tympanometry data and the patient's history, are transmitted electronically to the ENTs in Anchorage.
"With telepractice, we get a response within 24 hours," Hofstetter said. "Overnight, we have consults and prescribed treatments." Telepractice has been especially effective in facilitating medical clearance for hearing aids, assessing the need for surgery, surgical follow-up, and assessing the urgency of conditions. About a third of the 2,000 annual audiology patients are seen via telepractice; surgeries, MRIs, and CT scans require patients to travel to Anchorage.
NSHC also uses limited real-time telepractice in two capacities. "We'll send a new ear mold or hearing aid to a remote clinic," Hofstetter said, "and use teleconferencing to walk the clinic health aide through trimming the molding or tubing and fitting the patient." But the connections are via satellite—not land lines—resulting in real-time delay, audio problems, and networking problems. He also uses videoconferencing and store-and-forward telepractice to supervise a fourth-year AuD resident doing her clinical externship.
Hofstetter has been reviewing patient records dating back to 1992 to determine changes in wait times for initial ENT appointments and procedures. "We have dramatic results," he said. "Our data indicate a precipitous decrease in wait time and huge monetary savings."