Professional Issues in Telepractice for Speech-Language Pathologists
About this Document
This professional issues statement was developed by the Ad Hoc Committee on Telepractice in Speech-Language Pathology, which was appointed in 2008 by the ASHA Board of Directors. Members of the committee were Pauline Mashima (chair), David M. Brennan, Michael Campbell, Diana Christiana, Vickie Pullins, and Janet Brown (ex officio). Vice President for Professional Practices in Speech-Language Pathology Brian Shulman (2006–2008) and Vice President for Speech-Language Pathology Practice Julie Noel (2009–2011) served as the ASHA monitoring vice presidents. ASHA staff members Janice Brannon and Amy Hasselkus also contributed to the statement. This document was approved by the ASHA Board of Directors (06-2010) in 2010. The statement was developed utilizing the experience and consensus views of this select group of experts. It is not a clinical guideline or evidence-based systematic review; rather, its purpose is to clarify aspects of this mode of service delivery.
ASHA has tracked the use of remote service delivery by speech-language pathologists (SLPs) since 1998 and maintains updated information on its Web site (www.asha.org/telepractice). In 2004–2005, ASHA's Telepractice Working Group developed a position statement, technical report, and knowledge and skills statement to provide information and guidance about the use of telecommunications technology in speech-language pathology (ASHA, 2005d, 2005e, 2005f) and audiology (ASHA, 2005a, 2005b, 2005c). In response to the rapid advancement of technology and growing interest in this method of service delivery, an ad hoc committee was appointed to update the 2005 documents as needed. This document therefore serves as a supplement to the 2005 documents (ASHA 2005d, 2005e, 2005f), and the reader is advised to consult those documents to obtain a full perspective on issues related to service delivery at a distance.
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ASHA initially adopted the term telepractice rather than the frequently used terms telemedicine or telehealth to avoid the misperception that these services are used only in health care settings. Terminology has continued to evolve, and many disciplines have adopted terms specific to their professions. Other terms such as telespeech and teleaudiology and speech teletherapy may be used in addition to telepractice. Services delivered by SLPs and audiologists are also included in the broader generic term telerehabilitation (American Telemedicine Association, n.d.). For clarity and consistency, the term telepractice will be used throughout this document. Regardless of the term being used, ASHA adheres to the definition stated in the 2004 position statement:
Telepractice is the application of telecommunications technology to deliver professional services at a distance by linking clinician to client, or clinician to clinician for assessment, intervention, and/or consultation (ASHA, 2004a).
The position statement also includes an essential provision regarding quality and ethics:
The use of telepractice does not remove any existing responsibilities in delivering services, including adherence to the Code of Ethics, Scope of Practice, state and federal laws (e.g., licensure, HIPAA, etc.), and ASHA policy documents on professional practices. Therefore, the quality of services delivered via telepractice must be consistent with the quality of services delivered face-to-face (ASHA, 2004a).
For further clarification, face-to-face services will subsequently be referred to as in-person, since videoconferencing offers face-to-face communication at a distance. Supervision, mentoring, and pre-service or continuing education are other activities that may be conducted through the use of technology. However, these activities are not included in ASHA's definition of telepractice, and are best referred to as distance supervision and distance education. Such activities should be clearly described, as they may be regulated by universities and licensing, accrediting, and certifying organizations, as well as by payers.
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Technology provides opportunities to use a variety of communication modalities to interact with clients. However, not all uses of technology may be deemed telehealth encounters. Given the rapid emergence of technologies and programs, it is critical that the nature of the service and the role of the clinician during the service be clearly documented.
A telepractice session or encounter typically consists of real-time audio and visual connection between a client (or group of clients) and a clinician, analogous to an in-person diagnostic or treatment session.
Online clinical materials, paced software programs, and other “digital” therapy tools can serve as adjuncts to live interactions.
Other forms of telecommunications technology can be used to supplement service delivery (e.g., telephone, fax, and e-mail).
Telepractice venues have included schools, medical centers, rehabilitation hospitals, community health centers, outpatient clinics, universities, clients' homes, residential health care facilities, child care centers, and corporate settings. There are no inherent limits to where telepractice can be implemented as long as the services comply with national, state, institutional, and professional regulations or policies.
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The use of technology is an inherent element of telepractice. Specifications and selection of the appropriate equipment and connectivity will vary according to the telepractice application and desired outcomes. Technical support and training on use of telepractice equipment are essential elements for success; further, these needs will be ongoing as technology continues to evolve.
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Quality assurance and collection of outcomes data should be an integral part of developing telepractice services. As with in-person services, telepractice services should be supported by available evidence. Elements of quality assurance include the competency of providers, selection of clients, appropriateness of technology to the service being delivered, identification of appropriate outcome measures, collection of data, and satisfaction of the client, caregiver, and provider.
Telepractice services must conform to professional standards, including the Code of Ethics (ASHA, 2010). ASHA's Code of Ethics, Principle I, Rule K states that clinical services may not be provided solely by correspondence. Rule L states that telehealth may be practiced where not prohibited by law (ASHA, 2010). Principle II, Rule B states that clinicians “…shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience."
In addition to delivering professional services in accordance with ASHA's Preferred Practice Patterns, policy documents, and available evidence, clinicians must also be competent in delivering these services via an electronic communications environment. ASHA's 2005 document Knowledge and Skills for Speech-Language Pathologists Delivering Services Via Telepractice (ASHA, 2005d) describes specific areas of competency for delivering telepractice services, including selection of clients and technology that are appropriate for the service being delivered.
Optimal audio and video quality is dependent on the consistent and reliable operation and connection of telehealth equipment and networks.
Telepractice service delivery includes the responsibility for calibration and maintenance of clinical instruments and telehealth equipment in accordance with standard operating procedures of the telehealth site(s) and manufacturer's specifications (Denton, 2003). Services should also be in compliance with safety and infection control policies and procedures.
Telepractice services should be evaluated for efficiency, clinical effectiveness, and client, caregiver, and provider satisfaction.
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In delivering clinical services via telepractice, it is important to establish criteria for candidacy, define expected outcomes, develop telepractice clinical protocols that are based on existing evidence, evaluate the effectiveness of services, provide staff education and training, and manage potential risk.
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SLPs should be aware of regulatory and credentialing issues in the states in which they practice, and comply with any existing regulations for telepractice.
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Prior to initiating a telepractice program, it is essential to gain the support of stakeholders including clinicians, clients, administrators, sponsors/payers, technical and support staff, teachers, multidisciplinary team members, and parents/family members. Knowledge of and advocacy for reimbursement mechanisms are critical to sustain telepractice programs.
Organizational support is critical to successful implementation of telepractice. Ideally, the telepractice program should be included in the institution's strategic plan to demonstrate administrative approval and commitment, including allocation of organizational resources (Scheideman-Miller, 2004; Tracy, 2004).
Success in developing and sustaining telepractice programs is dependent on integrating these programs into existing organizational processes, personnel networks, and training activities.
Providers planning to deliver telepractice services are encouraged to engage in pre-implementation planning with their technical support staff to discuss issues such as managing firewalls and ensuring that sufficient bandwidth will be available to prevent interruption or degradation of the connection.
Scheduling services involving clinicians and clients at various sites requires planning and organization. Using a centralized scheduler who is familiar with participating sites, personnel, and telepractice processes can facilitate organizing patient information and coordinating telepractice encounters, which may involve multiple locations and time zones (Spaulding, Doolittle, & Swirczynski, 2004).
Before delivering telepractice services, SLPs should verify the coverage of telepractice with the payer of the services as well as the payers' requirements for billing, coding, and documentation.
School-based services are typically arranged through contracts with the local education agency or school district or provided by SLPs employed by the district.
Policies for reimbursement of speech-language pathology services by Medicaid vary from state to state.
Some states have passed legislation stating that services covered by private insurance must be reimbursed if provided via telehealth.
Advocacy for coverage by payers (e.g., schools, state Medicaid programs, private health plans) may contain the following information:
ASHA's policy documents supporting the use of telepractice,
A bibliography of peer-reviewed journal articles demonstrating comparable results between telepractice and in-person services,
Cost savings projections (e.g., travel time or mileage),
Demonstration of improved access or availability of specialized services to remote geographic areas or underserved clients.
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Ongoing research is needed to expand the evidence base for telepractice.
Future research should continue to investigate clinical and operational aspects of telepractice. This includes the study of, for example, (a) technological requirements to support diagnostic protocols and intervention procedures; (b) clinical efficacy and effectiveness; (c) client, clinician, and caregiver satisfaction; (d) determination of client candidacy for telepractice; (e) cost-benefit analyses; and (f) practical implementation issues such as scheduling, workflow, and organizational readiness (Hill & Theodoros, 2002; Jarvis-Selinger et al., 2008; Krupinski et al., 2002, 2006; Mashima & Doarn, 2008).
Studies should be conducted across a range of service delivery locations including controlled trials in laboratory settings and real-world locations such as clinics, schools, and client homes in both rural and urban areas.
Clinicians and researchers are encouraged to disseminate their findings through publications, courses, and trainings to provide colleagues, policymakers, and administrators with an evidence-based foundation for informed decision-making regarding telepractice applications.
Such investigations are not limited to telepractice in speech-language pathology, but can also be addressed collaboratively across disciplines.
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Telepractice has the potential to significantly improve access to speech-language pathology services. As models of clinical service delivery continue to change and new technologies emerge, telepractice services will continue to evolve and expand. In turn, SLPs will need to acquire the necessary technical and clinical skills to practice telepractice competently, ethically, and securely for the benefit of their clients and families.
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Asynchronous: A method of exchanging information (such as “store and forward” transmission) that does not require the client and the provider to be available at the same time. Common examples of asynchronous communication may include e-mails, faxes, recorded video clips, audio files, virtual technologies, e-learning programs, and so on.
Bandwidth: A measure of the information-carrying capacity of a network. The quality of the visual and auditory signal is proportional to the amount of bandwidth; the higher the bandwidth, the greater the amount of data that can be transmitted in a given time period.
Computer Interfacing: The connecting of a computer to another device.
Document camera: A camera that captures and displays real-time images during a telepractice encounter (e.g., text, photos, objects).
Dual Streaming Presentation: The transmission of two compressed multimedia images at the same time.
Encryption: A system of encoding data to assure that it is shared only by authorized users.
Firewall: Computer hardware and software that block unauthorized communications between an organization's internal network (LAN) and the external network (WAN).
High Definition (HD): The increase in display or visual resolution from standard definition (SD).
Interoperability: The ability of two or more systems to interact with one another and exchange data to achieve predicable results.
Local Area Network (LAN): An internal network over a small geographic area.
Multipoint Call: The interactive communication between multiple users at more than two sites.
Network: A group of computers connected by hardware and software.
Synchronous: Interactive transmission of data occurring bidirectionally in “real time” and, therefore, requiring the client and the provider be available at the same time.
VPN (Virtual Private Network): A network that uses a public telecommunications infrastructure, such as the Internet, to provide remote offices or individual users with secure access to their organization's network.
WAN (Wide Area Network): An external network over a large geographic area that links LANs.
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