When a patient is in danger of developing oropharyngeal dysphagia, that patient's life may hang in the balance. Immediate assessment is necessary, but difficult in remote or underserved communities that lack speech-language pathologists with the appropriate swallowing expertise.
A similar level of expertise is necessary to complete a clinical bedside exam or to interpret instrumental swallowing studies. Many communities lack SLPs with this expertise—or simply do not have access to videofluoroscopy or videoendoscopy services. SLPs may travel to a client's location to perform an evaluation; extended travel for a patient, however, is expensive, inconvenient, and tiring—which may affect an evaluation's outcome.
Because visual imaging is necessary to assess the competency of safe pharyngeal clearing, we sought a way to bridge the expertise gap in remote locations. New telepractice technology permitting real-time, interactive evaluation of swallowing shows promise in allowing remote clinicians to perform dysphagia assessments as accurately as those performed face-to-face, according to our recent NIH-funded study.
Remote vs. Onsite Evaluation
We sought to determine whether the results of a "telefluoroscopic" evaluation of swallowing, conducted through remote transmission of images, would agree with results of an evaluation performed by an SLP in the fluoroscopy suite (Malandraki, McCullough, McWeeny, He, & Perlman, 2011).
To this end, an SLP and a doctoral student in computer science created the Teledynamic Evaluation Software System (TESS; Perlman & Witthawaskul, 2002), which uses two computers. The first connects to a fluoroscope at a remote hospital and captures, transmits, and stores videofluoroscopic images. The second, located in the University of Illinois at Urbana-Champaign (UIUC) Swallowing Research Laboratory, captures the video in real time.
Over two years, we evaluated 32 patients with a primary diagnosis of stroke or head/neck cancer at the University of Arkansas for Medical Sciences (UAMS) Medical Center. Each participant first completed a clinical bedside swallowing assessment with an onsite SLP.
We provided the results—including patient history—to the UAMS study clinician and to the off-site clinician at UIUC, so both sites had the same information at the start of fluoroscopy. Participants then received two videofluoroscopic swallowing studies conducted back-to-back in random order. The clinician at the research lab directed one study via telemedicine—which was completed at the medical center by an assisting SLP—and the clinician at the medical center directed and completed the other study.
The two clinicians had the same ratings for severity of symptoms in 60% of the cases and were within one point of disagreement (on a four-point scale: normal–mild–moderate–severe) for all others. The mean absolute difference in scoring on the eight-point Penetration-Aspiration scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) was 1.1 points for all participants. This scale measures airway invasion with scores from one (normal swallowing) to eight (silent aspiration).
These levels are comparable to—if not better than—levels of agreement when two or more clinicians evaluate the same videofluoroscopic swallow study. Thus, we found not only good overall clinical agreement, but also replicability of results across two studies (i.e., test-retest reliability). Our results, therefore, suggest a patient can be rated by different clinicians in different studies performed on the same day, with very similar results.
Given the wide variety of treatment choices and the fact that different clinicians may recommend different treatments for the same underlying pathology, we grouped individual treatment recommendations into categories, such as altering meal habits or using postural adjustments. Agreement within each recommendation category was moderate to high. We noted individual discrepancies within categories, but most were likely attributable to clinician's training, clinical opinion, and experiences—factors that also would affect reliability without the use of telepractice.
Challenges and Solutions
Evaluating swallowing function is one of the more challenging and important responsibilities of a hospital-based SLP. Telepractice adds new challenges, but we believe they are worth the effort to resolve. The chart [PDF] lists a number of challenges for remote dysphagia evaluation and rehabilitation, along with proposed solutions for clinician-researchers.
Transmission delays. With the current TESS software, a one- to two-second delay occurs during online transmission. Given that the duration of the pharyngeal stage of a normal swallow is less than one second, this delay—although minimal—potentially could affect interpretation and swallowing safety. To overcome this issue, the SLP at the medical center was responsible for completing the orders given by the off-site swallowing laboratory clinician, and also for securing the patient's safety. In actual practice, an SLP typically is not onsite during a telefluoroscopic evaluation. Therefore, prior training of the radiologist and/or radiology technician is advisable.
Medical records. In the study, the remote examiner had access to basic medical history information but not the entire medical record. Remote access to full medical records of patients should be allowed for optimal assessments to be completed. This access now appears possible with advancements in secure transmission made since the time of the study.
Image quality. During a videofluoroscopic swallowing assessment, the clinician has to make decisions quickly and efficiently. Each image the clinician observes dictates decisions about next steps, requiring rapid transmission and pristine image quality. However, the quality of images during online transmission was reduced at times, making it difficult for the off-site clinician to perform the online evaluation at the desired level of image precision. Possible reasons for this phenomenon could be Internet connectivity issues, overload of Internet transmissions at peak-use times, or radiologic and/or computer equipment failures.
To avoid image-quality issues in online transmission, we tried to complete examinations early in the morning or at other times when neither the hospital nor university Internet connections were overloaded. Since then, Internet transmission and bandwidth have significantly improved, so this issue may be resolved by securing faster Internet connections between sites.
A few human errors and equipment failures also occurred and usually required small interventions, such as restarting the equipment, replacing batteries, or ensuring complete connection of cables. It is advisable to involve the local technology assistant or media department in setting up and maintaining software and hardware systems.
Specialized computer systems developed recently allow remote completion of high-quality clinical, non-instrumental assessments of swallowing (Ward et al., 2009). The future of telepractice in the evaluation of oropharyngeal dysphagia is promising, given the continuous development of new cameras, microphones, and lightweight portable computers; the increasing availability and connectivity of portable physiological data devices (e.g., heart and respiratory rate monitors); and the increasing speed and security of Internet connections. However, research also is needed to examine short- and long-term outcomes of patients evaluated and treated through telepractice.
With telepractice, we can bring the best possible care to individuals who are otherwise inaccessible because of distance, language, or clinical expertise barriers. Traveling several hours to receive good care may not be the "greenest" option, and also can result in patient fatigue that negatively affects an evaluation's outcome. SLPs can become leaders in reducing the disparity and economic burden of health care across the globe.
As our population increases and diversifies, specialists are needed who speak the language of their patients, understand cultural sensitivities, and provide best practice worldwide in an economically and ecologically efficient manner.
Telepractice is a viable method we should continue to explore, study, and use to meet the needs of the world that—through technology—is rapidly shrinking.
The authors thank Xuming He and Elizabeth McWeeny (co-authors of the research article), as well as Wee Witthawaskul, Juan Shen, and Jaime Olson, for their valuable help. This work was supported by the RO1 DC005603-01A2 awarded to the last author by the National Institute of Deafness and Other Communication Disorders of the National Institutes of Health.