Introduction

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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Terminology and Definition

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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Telepractice Services in Speech-Language Pathology

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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Telepractice Technology

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.

• Modes of Delivery

  • Synchronous (i.e., real-time) delivery modes have been used for capturing, transmitting, receiving, and presenting voice, data, and images in telepractice applications. Many studies have examined synchronous interactive audio-video teleconferencing as a method for providing speech-language pathology services in areas such as aphasia, fluency, speech, language, cognitive communication, voice, and swallowing disorders (Brennan, Georgeadis, Baron, & Barker, 2004; Duffy, Werven, & Aronson, 1997; Georgeadis, Brennan, Barker, & Baron, 2004; Grogan-Johnson, Alvares, Rowan, & Creaghead, 2010; Hill, Theodoros, Russell, Cahill, Ward, & Clark, 2006; Kully, 2000; McCullough, 2001; Mashima et al., 2003; Palsbo, 2007; Perlman & Witthawaskul, 2002; Rose et al., 2000; Scheideman-Miller et al., 2002; Sicotte, Lehoux, Fortier-Blanc, & Leblanc, 2003; Theodoros, Hill, Russell, Ward, & Wootton, 2008; Theodoros et al., 2006; Waite, Cahill, Theodoros, Busuttin, & Russell, 2006).

  • Asynchronous applications such as the storing and forwarding of data have been used as an adjunctive mode to supplement services delivered in person or to review and validate information observed and recorded during synchronous telepractice encounters (Hill et al., 2006; Lewis, 2006; O'Brian, Packman, & Onslow, 2008; Perlman & Witthawaskul, 2002; Theodoros et al., 2006, 2008; Waite et al., 2006; Wilson, Onslow, & Lincoln, 2004).

• Videoconferencing Equipment

  • Videoconferencing hardware, software, and peripheral devices will continue to change as they incorporate advances in and introduction of new telehealth technologies.

  • Video communication can be accomplished through the use of personal videophones, videoconferencing software, and dedicated videoconferencing hardware.

  • Selection of videoconferencing equipment should include consideration of camera capabilities (e.g., pan-tilt-zoom [PTZ] and resolution), display monitor capabilities (e.g., size, resolution, and dual display), microphone and speaker quality, and multisite capability.

  • Peripheral devices may include recording devices or auxiliary video input equipment for computer interfacing, document camera presentation, or utilization of other specialized cameras with high resolution (e.g., fiberoptic videoendoscopes).

  • Additional modes of real-time interaction may be provided through applications such as screen sharing, whiteboards, online presentations, or text chat.

• Connectivity

  • During telepractice, information is transmitted across a telecommunications connection between participants at different sites.

  • Network connection speed impacts overall quality of video and audio clarity. In a review of 225 articles focused on videoconferencing in clinical contexts, including speech-language pathology, a minimum bandwidth of 384 Kbps was needed in most applications to establish adequate audio and visual clarity (Jarvis-Selinger, Chan, Payne, Plohman, & Ho, 2008).

  • Available bandwidth may be reduced by the number of users on the communication network at any point in time.

  • Higher connection speeds may be required for high definition (HD), dual streaming video presentation, or hosting multipoint calls. Lower bandwidth may result in delays, jitter, and loss of data, and interfere with quality of signals for clinical decision making or normal turn taking in conversational discourse.

  • Consideration should be given to establishing an alternative connection (e.g., telephone, e-mail) for participants to troubleshoot connection problems or to reschedule the session.

  • Lack of technological compatibility may be a barrier to connecting sites with different hardware, software, and bandwidth speeds. A financial investment may be required to upgrade the infrastructure to ensure the interoperability of equipment at all participating sites.

  • Secure transmission during telepractice may be obtained through the use of encryption, secure connection via virtual private network (VPN), and hardware/software firewalls.

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Quality of Telepractice Services

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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Clinical Practice

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.

• Client Candidacy

  • Because clinical services are based on the unique needs of each individual client, telepractice may not be appropriate in all circumstances or for all clients. Determining candidacy for telepractice is based on available information about the client's behavioral, physical, sensory, and cognitive abilities to participate in services provided from a distance and the clinician's professional judgment (ASHA, 2005c, 2005f).

  • Contraindications for the use of telepractice include clinical procedures that require direct physical contact (e.g., assessing muscle tone or strength).

  • Exclusion criteria include clients who need hands-on guidance (e.g., for safety reasons or to establish target behaviors) or clients with attention, hearing, vision, or cognitive deficits that limit their ability to communicate or interact with the clinician from a distance via technology.

  • Another factor in determining candidacy may be the availability of a facilitator who has the level of training needed to assist at the client's location.

  • Clients who are not appropriate candidates for telepractice services should be referred for in-person service delivery.

• Clinical Protocols

  • Assessment and therapy procedures and materials may need to be modified and adapted to accommodate for the lack of physical contact with the client. While not all tools have been validated for use via telepractice, studies have examined various protocols with different client populations and clinical disorders (Brennan et al., 2004; Duffy et al., 1997; Georgeadis et al., 2004; Hill et al., 2006; Mashima et al., 2003; O'Brian et al., 2008; Palsbo, 2007; Scheideman-Miller et al., 2002; Theodoros et al., 2006, 2008; Tindall, Huebner, Stemple, & Kleinert, 2008; Waite et al., 2006; Ward et al., 2007; Wertz et al., 1992; Wilson et al., 2004).

  • Clients should receive orientation and training in the use of telepractice equipment and the telepractice protocol to a level that is appropriate for each client.

• Environment

  • Attention to environmental elements of care is important to ensure the comfort, safety, confidentiality, and privacy of clients during telepractice encounters. Room location, design, lighting, and furniture should optimize the quality of video and audio data transmission, and minimize ambient noise and visual distractions in all participating sites (University of Hawaii, 2001).

  • Advance planning and preparation is needed for optimal positioning of the client and test and therapy materials, and for placement of the video monitor and camera (Jarvis-Selinger et al., 2008).

• Use of Facilitators

  • Facilitators may be used in telepractice encounters to assist clients on site. The SLP is responsible for conducting the session and directing the activities of the facilitator. The facilitator may be a teacher's aide, a nursing assistant, a speech-language pathology assistant or other type of support personnel, an interpreter, a family member, and so on, unless specified by institutional or other policies or regulations.

  • The SLP is responsible for ensuring that the facilitator is appropriately trained to provide the type of assistance needed. Activities may include (a) escorting clients or students to and from sessions, (b) establishing and troubleshooting the telepractice connection, (c) setting up therapy materials, (d) positioning the client at the direction of the SLP, (e) remaining with the client or student during sessions, (f) assisting with behavior management as needed, (g) communicating with on-site staff or teachers about scheduling, and (h) in some instances serving as the interpreter.

• Culturally/Linguistically Diverse Populations

  • Telepractice enables SLPs to extend their services to underserved communities. This includes communities in remote geographic areas as well as those in close proximity where cultural and linguistic differences impact service delivery.

  • Participating personnel must understand the local culture and the impact of regional dialects, and communicate effectively in a culturally appropriate manner (Information Management Group, 2001).

• Indirect Services

  • When implementing telepractice programs, it is important to coordinate care with other providers who interact with clients and clients' families. Providing services at a distance may require advance planning to participate in care coordination.

• Privacy and Confidentiality

  • Protecting the privacy of patient records and information is mandated by ASHA's Code of Ethics Principle I, Rules K and L, (ASHA, 2010) as well as federal and state laws and regulations. Security of treatment rooms and remote access to electronic documentation must be considered to protect client privacy and confidentiality at both sites. All persons in rooms at both sites should be identified prior to each session or when entering the session. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) consists of three rules: Security, Privacy, and Electronic Transactions. HIPAA-covered entities are (a) health care providers who conduct certain transactions in electronic form, (b) health plans, and (c) health care clearinghouses. Covered entities and business associates must comply with all HIPAA rules and regulations. Private practitioners are not HIPAA-covered entities if they do not bill electronically and they are not business associates of covered entities.

    • Of the HIPAA rules, the Privacy Rule is relevant to the actual telepractice session conducted by covered entities. HIPAA addresses the privacy of protected health information (PHI). Covered entities must take reasonable measures to ensure the privacy of a patient's PHI. Telepractice sessions must be protected from unauthorized access; the method of protection is not specified by HIPAA, and may vary depending on the risks associated with different types of equipment and connections. HIPAA-covered entities must perform a risk assessment and document strategies that they will implement to ensure patient privacy.

    • HIPAA Security and Privacy Rules also apply to electronic transactions (e.g., claims, coverage information) that include PHI. All HIPAA-covered entities are required to comply with these requirements.

  • The Family Educational Rights and Privacy Act (FERPA) protects the privacy of students' records but does not specifically address privacy in telepractice. FERPA addresses telepractice in school settings through its 2008 revised definition of attendance (34 CFR Part 99, www.ed.gov/legislation/FedRegister/finrule/2008-4/120908a.pdf) to include “videoconference, satellite, Internet, or other electronic information and telecommunications technologies for students who are not physically present in the classroom.” Services delivered to students covered by Medicaid must also comply with HIPAA.

• Documentation

  • In addition to meeting existing documentation requirements, records of telepractice clinical encounters should identify that services were delivered via telehealth, and include information on the type of equipment used, transmission medium, and any modifications that were made to standardized assessment or treatment procedures.

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Licensure and Credentialing

SLPs should be aware of regulatory and credentialing issues in the states in which they practice, and comply with any existing regulations for telepractice.

• Licensure

  • To date, a small number of state licensure boards have addressed telepractice in their legislation or regulatory language. Considerable variability exists among these states in their terminology and the specificity of their regulations. As the use of telehealth increases, more states are expected to develop some form of guidance.

  • For SLPs as well as other licensed professionals, obtaining full licensure in multiple states creates a barrier to interstate practice. Such restrictions may inhibit access for clients and increase costs for the delivery of service. Other options, such as limited licensure, may allow states to monitor telepractitioners providing services in their state without unduly restricting practice. Collaboration among state licensure boards to achieve consistency in terminology and regulations would have a positive effect in streamlining processes and reducing barriers at a state and national level.

• International Practice

  • ASHA-certified SLPs delivering telepractice services to individuals in other countries are bound by the ASHA Code of Ethics and other official ASHA policy documents guiding ethical and appropriate practice. In addition, SLPs should comply with laws that regulate the practice of speech-language pathology within that country.

  • SLPs should ensure that the services they deliver are culturally and linguistically sensitive.

• Other Credentialing and Guidance

  • Guidance for the use of telehealth has been developed by professional organizations such as ASHA, the Canadian Association of Speech-Language Pathology and Audiology, the American Occupational Therapy Association, and the American College of Radiology. The American Telemedicine Association, an industry/professional organization, develops standards and guidelines in various areas of practice (American Telemedicine Association, n.d.).

  • In addition, other organizations, institutions, payers, and accrediting and regulatory bodies may also develop requirements or guidance for telehealth or telemedicine programs. For example, the Joint Commission, an organization that accredits health care facilities, has had standards for telemedicine since 2001.

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Administrative

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.

• Support

  • 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

  • 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).

• Reimbursement

  • 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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Research Needs

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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Summary

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.