See the Telepractice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Telepractice is the delivery of services using telecommunication and Internet technology to remotely connect clinicians to clients, other health care providers, and/or educational professionals for screening, assessment, intervention, consultation, and/or education. Telepractice is an appropriate model of service delivery for audiologists and speech-language pathologists (ASHA, n.d.) and may be the primary mode of service delivery or may supplement in-person services (known as hybrid service delivery).
Technology may also be used for supervision, mentoring, preservice, and continuing education. However, these activities are not included in ASHA’s definition of telepractice and are best referred to as telesupervision/distance supervision and distance education. See ASHA’s Practice Portal page on Clinical Education and Supervision for further information.
ASHA 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. Other terms such as teleaudiology, telespeech, and speech teletherapy are also used by practitioners in addition to telepractice. Services delivered by audiologists and speech-language pathologists are included in the broader generic term telerehabilitation (American Telemedicine Association, 2010).
Use of telepractice should be of equal quality to services provided in person and consistent with adherence to ASHA’s Code of Ethics (ASHA, 2016a), Scope of Practice in Audiology (ASHA, 2018), Scope of Practice in Speech-Language Pathology (ASHA, 2016b), and Assistants Code of Conduct (ASHA, 2020) as well as state and federal laws (e.g., licensure, Health Insurance Portability and Accountability Act of 1996 [U.S. Department of Health and Human Services, n.d.-b]). Please see ASHA State-by-State for further information on issues related to audiology and speech-language pathology at state and local levels.
There are no inherent limits to where telepractice can be implemented, as long as the services comply with national, state, institutional, and professional regulations and policies. See ASHA State-by-State for state telepractice requirements.
Common terms describing types of telepractice are as follows:
Some telepractice services (e.g., remote patient monitoring) currently cannot replace the services provided by an evaluation or a treatment session and may not be considered reimbursable telehealth by payers. Clinicians and programs should verify state licensure and payer definitions to ensure that a particular type of telepractice service delivery model is consistent with regulation and payment policies. See the Reimbursement section below for further details.
Roles and responsibilities for audiologists and speech-language pathologists (SLPs) in the provision of services via telepractice include
Ongoing education and training are required to maintain expertise and familiarity with changes in technology and potential clinical applications (Towey, 2012a).
ASHA requires that individuals who provide telepractice abide by the ASHA Code of Ethics (ASHA, 2016a). Also, see papers by Cohn and Cason (2019), Denton and Gladstone (2005), and Meline and Mata-Pistokache (2003) for further information.
States may have legal or regulatory requirements regarding telepractice. Clinicians verify state licensure requirements and policies in the state from which the clinician provides services and the state in which the client receives services prior to initiating services. Clinicians should also verify requirements including temporary location changes such as vacations and college attendance.
Current guidance in medical and legal practices indicates that the client’s location is the originating site (i.e., site of service) and the provider’s location is considered the distant site. ASHA guidelines assert that telepractitioners must be licensed in both the state from which they provide services and the state where the client is located at the time of service. ASHA, along with its state regional organizations, has now established the Audiology & Speech-Language Pathology Interstate Compact (ASLP-IC). The ASLP-IC is intended to allow professionals to practice in multiple states without having to obtain additional state licenses. For updates on the compact, please see ASHA’s resource on Audiology & Speech-Language Pathology Interstate Compact (ASLP-IC) and the ASLP-IC website.
Civilian employees of the Department of Defense and the Department of Veterans Affairs may not be bound by the same licensing requirements. Confirm the specific licensing requirements for your circumstances.
Clinicians planning to do telepractice in a school setting in a state other than where they reside should communicate with the Department of Education and the licensure board (in the state where service is provided) to determine whether licensure and/or teacher certification is required and to obtain further guidance as appropriate.
See ASHA’s state telepractice and telesupervision requirements (select your state for detailed information).
ASHA-certified audiologists and SLPs who deliver telepractice services to individuals in other countries are bound by ASHA’s Code of Ethics (ASHA, 2016a), Scope of Practice in Audiology (ASHA, 2018), Scope of Practice in Speech-Language Pathology (ASHA, 2016b), Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006), and Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 2004).
Prior to providing international telepractice services, it is important to
ASHA recommends that practitioners check their professional liability status and consult with the regulatory body in that country.
Historically, coverage and payment of telepractice services varies widely across federal, state, and commercial payers (e.g., Medicare, Medicaid, private health insurance). During the COVID-19 Public Health Emergency, temporary policies and exceptions were implemented to increase access to telepractice services. Some telepractice models (e.g., remote patient monitoring) may not be reimbursable by current coverage and payment standards. It is critical for clinicians to verify telepractice coverage and billing guidelines by the client’s payer before initiation of services. See Payment and Coverage of Telepractice Services: Considerations for Audiologists and Speech-Language Pathologists for detailed coding, Medicare, Medicaid, and commercial insurance information.
Telepractice providers should be prepared to educate payers about how telepractice services are delivered and the benefits to clients and payers. Educational materials may include research articles, organization policies and procedures to ensure provider training and quality services, educational/informed consent materials for clients, video clips, and testimonials.
See the ASHA State-by-State page for further details.
Telepractice may not be appropriate in all circumstances or for all clients. Consider each client’s familiarity/experience with telepractice/technology, the availability of Internet/technology/support, each client’s desire to use telepractice and ability to interact/engage via telepractice, and any other relevant items. Clinicians may explore the benefits and challenges of other service delivery models before initiating telepractice services. Telepractice may be used for a trial period to confirm whether it is an appropriate service delivery model. Training and/or consultation via telepractice may be provided to the client’s family/caregivers or to other health care providers, as appropriate, for clients who are either unable to interact/engage via telepractice or not benefiting from services via telepractice. However, such services may not be reimbursable in the absence of the patient.
Clinicians assist in determining eligibility for services and making progress toward goals via telepractice. Additional supports such as use of an interpreter; captioning; other online tools; and/or collaboration with family, caregivers, and facilitators may be appropriate for improving telepractice interactions and client outcomes.
The potential for telehealth to create new burdens for the client and caregivers should be considered and discussed during the decision-making process. The specific telehealth model may require the client and/or caregivers to assume responsibility for managing technology, gathering therapeutic materials, and assisting in the execution of specific therapeutic techniques. Ramifications of shifting care from the clinic or school to the client or family must be included in the client selection process (May et al., 2014).
Client characteristics that may potentially impact their ability to interact or engage via telepractice include the following:
Clinicians should pay deliberate attention to the physical and interpersonal aspects of a telepractice encounter. Advance planning and preparation are needed for optimal positioning of the client, test materials, and therapy materials and for placement of the video monitor and camera (Duane et al., 2021; Jarvis-Selinger et al., 2008).
Modifications to in-person verbal and nonverbal communication strategies may be needed to provide optimal service and to establish and maintain the client–provider relationship.
Captioning should be considered for all patients regardless of hearing status, so they do not have to rely on verbal information or visual information alone.
Attention to environmental elements is important to ensure the comfort, safety, confidentiality, and privacy of clients during telepractice encounters. Careful selection of room location, design, lighting, and furniture should be made to optimize the quality of video and audio data transmission and to minimize ambient noise and visual distractions in all participating sites. The clinician’s backdrop should be professional and free of clutter. A neutral background in shades of blue or gray improves appearance.
The growing body of research on the use of telepractice for communication disorders includes many studies demonstrating the comparability of telepractice and in-person services. Please see ASHA’s Telepractice Evidence Map for further information.
Computer-based clinical applications are common in audiology practice (Choi et al., 2007; Kokesh et al., 2009). Audiologists frequently use computer peripherals—such as audiometers; hearing aid systems; and auditory brainstem response, otoacoustic emission, and immittance testing equipment—that can be used in telepractice. Hearing instrument, cochlear implant, and audiologic equipment manufacturers are now promoting equipment with synchronous or store-and-forward capabilities.
Audiologists have used telepractice to provide audiological services, including, but not limited to, the following:
SLPs use telepractice to assess and treat various disorders, including, but not limited to, the following:
Clinicians who deliver telepractice services must possess specialized knowledge and skills in selecting assessments and interventions that are appropriate and valid when administered remotely. This decision must also take into consideration factors related to each individual client and disorder variables. Assessment and therapy procedures and materials may need to be modified or adapted to accommodate the lack of physical contact with the client. These modifications must be made transparent when interpreting and documenting services provided. Publisher permission is necessary to modify assessment materials in any way and may be provided on a case-by-case basis. Please check with the publisher before modifying assessment materials. Please see Considerations for Speech, Language, and Cognitive Assessment via Telepractice for further information.
Some publishers of standardized assessments have developed guidance about the administration of tests via telepractice or validated assessments for administration via telepractice. Other researchers have compared the validity of in-person and remote assessment protocols (Sutherland et al., 2016; Taylor et al., 2014; Thai-Van et al., 2020; Weidner & Lowman, 2020).
Telepractice services may be provided by private contractors with a local education agency or school district or by audiologists and SLPs employed by the district. The strategic use of telepractice addresses shortages of clinicians in some school districts, increases flexibility to meet workload demands by reducing travel to multiple schools, and improves accessibility to providers. Telepractice affords a more accessible and preferred format of service delivery for some students receiving direct services and assessments as well as for collaborating with staff and families receiving consultative services (Boisvert & Hall, 2019; Grogan-Johnson, 2021).
The effectiveness of telepractice as a service delivery model in the schools is well documented (Gabel et al., 2013; Grogan-Johnson et al., 2010, 2011; Lewis et al., 2008; McCullough, 2001; Sanchez et al., 2019). In addition, parents, clients, and clinicians report satisfaction with telepractice as a mode of service delivery (Crutchley & Campbell, 2010; McCullough, 2001; Rose et al., 2000; Sanchez et al., 2019).
The administrative body responsible for defining telepractice-based services in a school or school district
Some states allow reimbursement for eligible students covered by Medicaid when services are delivered via telepractice; however, the state’s Medicaid policy and coding guidance should be verified. See ASHA State-by-State and Payment and Coverage of Telepractice Services: Considerations for Audiologists and Speech-Language Pathologists for more information.
Specifications and selection of the appropriate hardware and software equipment and connectivity vary according to the telepractice application. Technical support and training in the use of telepractice equipment are essential for success, and these needs will be ongoing as technology continues to evolve.
Video communication may be completed via personal videophones, videoconferencing software, and dedicated videoconferencing hardware and secure web-based programs.
Factors/options in the selection of videoconferencing tools include the following:
There are three web conferencing option levels—business class, software-based, and public domain.
When selecting a web conferencing option,
During telepractice, information is transmitted across a telecommunications connection (e.g., point-to-point, dedicated line, web-based) between individuals at different sites.
Consider the following factors in determining an appropriate connection strategy:
In telepractice, a facilitator is an individual who is present at the client site to support the client and the remote clinician. The specific duties of facilitators depend on the service being provided (Coco et al., 2020). Duties may include assisting the client with hands-on tasks, helping manage local equipment/technology, monitoring client participation and safety, and supporting the remote clinician with on-site tasks (e.g., providing copies of documentation).
Unless restricted by institutional or state policies or regulations, any appropriately trained individual may act as a facilitator. The facilitator may be a teacher’s aide, a student clinician, an audiology assistant or a speech-language pathology assistant, a teleaudiology clinical technician, a licensed health care professional, an interpreter, other support personnel, or a family member/caregiver, as appropriate and as available. It is not preferable to have a family member act as both facilitator and interpreter in instances when interpretation is required. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators for further details.
It is the responsibility of the practitioner to direct the session and ensure that the facilitator is adequately trained to assist. Douglass et al. (2021) published a study proposing minimum competencies for tele-facilitators in the school setting. Adequate training includes knowledge of and sensitivity to clients’ cultural and linguistic differences as well as how such differences may influence participation in telepractice (see ASHA’s Practice Portal pages on Bilingual Service Delivery and Cultural Responsiveness).
Practitioners must be aware of applicable federal and state policies and regulations including privacy issues (e.g., HIPAA) and reimbursement allowances regarding the use of facilitators. Please see the ASHA Facilitator Checklist for Telepractice Services in Audiology and Speech-Language Pathology [PDF].
Interpreters may also be needed. Interpreting in telepractice may be done by videoconferencing or by telephone. Videoconferencing (or video interpreting) has the benefit of exchanging visual information. If using video interpreting, the interpreter may be located at the clinician site, the patient site, or a third separate site. Clinicians and facilitators should practice and become familiar with communicating with an interpreter in telepractice, including privacy and ethical concerns related to utilizing an interpreter. The hierarchy for preferred interpreters in telepractice is consistent with that used for interpreters during in-person practice (see ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators).
Practitioners should be aware of federal and state regulations relating to administrative, physical, and technical safeguards applicable to privacy and security, including those pertaining to storage, transmission, and disposal of client information.
Best practice is to use encrypted videoconferencing platforms to protect client confidentiality. The provider should be able to demonstrate encryption of the platform used for practice. Please see ASHA’s resource on Telepractice Services and Coronavirus/COVID-19 for further information.
Clinicians providing services via telepractice are bound by federal and state regulations as they would be when providing in-person services. The following federal legislation addresses privacy and security for covered entities:
States may also have privacy or security requirements that are more stringent than federal requirements. See ASHA’s resource on Health Insurance Portability and Accountability Act for general information about HIPAA. See also ASHA’s resources on HIPAA Security Rule: Frequently Asked Questions, HIPAA: Electronic Data Interchange (EDI) Rule, and HIPAA Security Technical Safeguards.
Determining how to be compliant with these regulations is complex. There are no absolute standards that dictate which software programs meet all requirements. Consulting an expert who specializes in these issues is advisable. Further discussion of the complexities of privacy is provided in the work of Cohn and Watzlaf (2011).
Security of treatment rooms and remote access to electronic documentation must be considered to protect client privacy and confidentiality at both sites. Clients should be given an opportunity to decide who is present at their location when they receive services, and a camera may be used to scan the clinician’s environment to ensure privacy. All persons in rooms at both sites should be identified prior to each session and when any individual(s) enters the room.
Clinicians obtain documentation of informed consent from the client (see Principle I, Rule H of the ASHA Code of Ethics (ASHA, 2016a) to manage risk. This may include
Documentation may also include
Client confidentiality should be maintained regardless of the mode of service delivery (i.e., in-person or telepractice). Please see Principle I, Rules O and P of the ASHA Code of Ethics (ASHA, 2016a). Telepractice confidentiality concerns include
When implementing a telepractice program, it is essential for practitioners to gain the support of stakeholders. A successful telepractice program requires mutual understanding, collaboration, and a receptive attitude toward telepractice on the part of all stakeholders.
Methods for enlisting support include
Telepractice may be one aspect of an institution’s or a company’s services, or it may be the exclusive focus. Audiologists and SLPs may have questions regarding how to determine whether a prospective employer provides appropriate training and support to enable them to deliver high-quality services.
The following are questions that could be explored by a potential telepractitioner:
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Telepractice page:
In addition, ASHA thanks the members of the Ad Hoc Committee on Telepractice in Speech-Language Pathology and the Telepractice Working Group whose work was foundational to the development of this content.
Members of the Ad Hoc Committee on Telepractice in Speech-Language Pathology were Pauline Mashima (chair), David M. Brennan, Michael Campbell, Diana Christiana, Vickie Pullins, and Janet Brown (ex officio). Vice Presidents for Professional Practices in Speech-Language Pathology Brian Shulman (2006–2008) and Julie Noel (2009–2011) served as the monitoring officers. ASHA staff members Janice Brannon and Amy Hasselkus also contributed.
Members of the ASHA Telepractice Working Group were Mark Krumm (chair), Gregg Givens, Amy C. Georgeadis, Pauline A. Mashima, John M. Torrens, Janet Brown (ex officio), and Pamela Mason (audiology staff consultant). Roberta B. Aungst, vice president for professional practices in audiology (2004–2006), served as monitoring vice president.
The recommended citation for the Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Telepractice. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Telepractice/.