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Telepractice

Overview

Telepractice is the application of telecommunications technology to the delivery of speech language pathology and audiology professional services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and/or consultation.

Supervision, mentoring, pre-service, and 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 telesupervision/distance supervision and distance education. See ASHA’s Practice Portal page on Clinical Education and Supervision for a detailed discussion of telesupervision.  

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 (SLPs) are included in the broader generic term telerehabilitation (American Telemedicine Association, 2010).

Use of telepractice must be equivalent to the quality of services provided in person and consistent with adherence to the Code of Ethics (ASHA, 2016a), Scope of Practice in Audiology (ASHA, 2018), Scope of Practice in Speech-Language Pathology (ASHA, 2016b), state and federal laws (e.g., licensure, Health Insurance Portability and Accountability Act [HIPAA; U.S. Department of Health and Human Services, n.d.-c]), and ASHA policy.

Telepractice venues include 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 and policies. See ASHA State-by-State for state telepractice requirements.

Common terms describing types of telepractice are as follows:

Clinicians and programs should verify state licensure and payer definitions to ensure that a particular type of service delivery is consistent with regulation and payment policies.

Key Issues

Roles and Responsibilities

Telepractice is an appropriate model of service delivery for audiologists and SLPs.

Roles and responsibilities for audiologists and SLPs in the provision of services via telepractice include

Telepractice is constantly evolving. Ongoing education and training is required to maintain expertise and familiarity with changes in technology and potential clinical applications. Web technology allows clinicians to engage clients through virtual environments and other personally salient activities (Towey, 2012a).

Ethical Considerations

ASHA requires that individuals who provide telepractice abide by the ASHA Code of Ethics (ASHA, 2016a), including the following specific principles denoted within:

Licensure and Teacher Certification

A growing number of states have legal or regulatory requirements regarding telepractice. Prior to initiating services, clinicians should verify state licensure requirements and policies regarding telepractice—including temporary location changes such as vacations and college attendance—in the state from which the clinician provides services and the state in which the client receives services.

Current guidance in medical and legal practices indicates that the client’s location determines the site of service. We remind readers that ASHA guidelines assert that telepractioners  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.  Recognizing that this can be a burden to practitioners and a barrier to the growth of telehealth, several professional health care organizations (e.g., nursing, physicians, and physical therapists) are in the process of developing licensure compacts that would facilitate a streamlined process to practice in other states. ASHA currently is supporting an initiative to explore a similar solution for audiologists and SLPs.

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 verify with the Department of Education and the licensure board (in that state) whether licensure or teacher certification—or both—are required. Private contractors or clinicians working for telepractice companies that are contracting in schools would have to have a state license.

See ASHA’s resource on  state telepractice requirements.

See maps of states [PDF] with written guidance on the use of telepractice in licensure law or regulation.

See maps of states [PDF] with written guidance on the use of telesupervision of clinical fellows, students (interns) and support personnel.

International Considerations

ASHA-certified audiologists and speech-language pathologists 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

Many possible international telepractice scenarios exist, such as treating American citizens who live abroad or on military bases or providing services to citizens of other countries. ASHA recommends that practitioners check their professional liability status and consult with the regulatory body in that country.

Reimbursement

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 maps of states with written guidance on telepractice reimbursement laws and regulations.

Private Health Insurance

Some states have passed insurance/parity laws (i.e., legislation mandating coverage of telepractice). Generally, the mandates require health insurers and health maintenance organizations to cover the cost of health care services provided through telepractice on the same basis as those provided through in-person visits. Insurers may reimburse for telepractice in states without mandates; however, given the variability of state requirements, the practitioner should first check with the payer and state regulations, if available. See ASHA State-by-State for more information.

See  maps of states [PDF] with written guidance on telepractice reimbursement laws and regulations.

Medicare

Medicare reimburses some providers for specific telepractice services under specified conditions, but audiologists, SLPs, and other rehabilitation professionals are not presently included in legislation as eligible providers. ASHA and other organizations have been actively lobbying for legislation to expand eligibility to include audiologists and SLPs, among others.

Beneficiaries can receive covered services only from enrolled providers and may not pay for telepractice services privately.

See  maps of states [PDF] with written guidance on telepractice reimbursement laws and regulations.

Medicaid

Medicaid is a federal/state entitlement program for low-income individuals and families. Each state

Practitioners should contact the appropriate state Medicaid office to verify how a telepractice service should be reflected in the billing code and documentation. See ASHA State-by-State for more information.

Client Selection

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. Candidacy for receiving services via telepractice should be assessed prior to initiating services. The client’s culture, education level, age, and other characteristics may influence the appropriateness of audiology and speech-language services provided via telepractice.

Consider the potential impact of the following factors on the client’s ability to benefit from telepractice:

Environmental Considerations

Attention to environmental elements of care 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.

Advance planning and preparation is needed for optimal positioning of the client, test materials and therapy materials, and for placement of the video monitor and camera (Jarvis-Selinger, Chan, Payne, Plohman, & Ho, 2008).

Practice Areas

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.

Audiology

Computer-based clinical applications are common in audiology today (Choi, Lee, Park, Oh, & Park, 2007; Kokesh, Ferguson, Patricoski, & LeMaster, 2009). For example, telepractitioners frequently use computer peripherals—such as audiometers, hearing aid systems, and auditory brainstem response (ABR), otoacoustic emissions (OAEs), and immittance testing equipment—that can be interfaced to existing telepractice networks. Manufacturers are now promoting equipment with synchronous or store-and-forward capabilities.

Teleaudiology is being used in the following practice areas:

Speech-Language Pathology

Telepractice is being used in the assessment and treatment of a wide range of speech and language disorders, including the following:

Modification of Assessment and Treatment Techniques and Materials

Clinicians who deliver telepractice services must possess specialized knowledge and skills in selecting assessments and interventions that are appropriate to the technology and that take into consideration 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 should be reflected in the interpretation and documentation of the service.

Some publishers of standardized assessments have developed guidance about administration of tests via telepractice or validated assessments for administration via telepractice (e.g., see Pearson’s guidelines on assessment via telepractice). Other researchers have compared the validity of in-person and remote assessment protocols (Sutherland et al., 2016; Taylor, Armfield, Dodrill, & Smith, 2014).

School Setting Considerations

Schools are currently the most common setting in which telepractice services are delivered. This is due to a number of factors, including shortages of clinicians in some school districts, distances between schools in rural areas, and opportunities to offer greater specialization within a district.

Telepractice services may be provided by private contractors with the local education agency or school district, or the services may be provided by audiologists and SLPs employed by the 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 for more information.

The effectiveness of telepractice as a service delivery model in the schools is well documented (Gabel, Grogan-Johnson, Alvares, Bechstein, & Taylor, 2013; Grogan-Johnson, Alvares, Rowan, & Creaghead, 2010; Grogan-Johnson et al., 2011; Lewis et al., 2008; McCullough, 2001).

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).

The administrative body responsible for defining telepractice-based services in a school or school district should

Telepractice Technology

The use of technology is an inherent element of telepractice. 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; further, these needs will be ongoing as technology continues to evolve.

Videoconferencing Tools (Hardware, Software, and Peripheral Devices)

Video communication can be accomplished through the use of personal videophones, videoconferencing software, and dedicated videoconferencing hardware and secure web-based programs.

Factors/options in the selection of videoconferencing tools include the following:

Considerations in Selecting a Web-Conferencing Collaboration Service

There are three web-conferencing option levels—business class, software-based, and public domain.

When selecting a web-conferencing option,

Connectivity

During telepractice, information is transmitted across a telecommunications connection (e.g., point-to-point, dedicated line, web-based) between participants at different sites.

Consider the following factors in determining an appropriate connection strategy:

Facilitators in Telepractice for Audiology and Speech-Language Services

Appropriately trained individuals may be present at the remote site to assist the client.  Unless restricted by institutional or state policies or regulations, the facilitator may be a teacher’s aide, nursing assistant, student clinician, audiology assistant or speech-language pathology assistant, teleaudiology clinical technician, telepresenter or other type of support personnel, interpreter, family member or caregiver, among others. Practitioners must be aware of applicable state policies and regulations regarding the use of facilitators.

The type of paraprofessional required at the remote site may vary depending on the type of service being provided. It is the responsibility of the pracitioner to direct the session and ensure that the facilitator is adequately trained to assist. 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 Competence). 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).

Privacy and Security

Practitioners should be aware of federal and state regulations relating to privacy and security, including those pertaining to storage and transmission of client 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. For example, a vendor cannot guarantee that a product is HIPAA compliant because the provider’s policies and how a provider implements a given program helps determine the effectiveness of the program’s privacy and security measures. Consulting an expert who specializes in these issues is advisable. Further discussion of the complexities of privacy is provided by 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 should be present at their locations 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 or when the individual(s) enters the session.

To manage risk, clinicians are advised to obtain documentation of informed consent from the client. This may include a description of the equipment and services to be delivered, how services via telepractice may differ from services delivered in person, the individual’s right to revert to traditional face-to-face care at any time, any modifications that will be made in assessment protocols, and potential confidentiality issues. Documentation may also include the type(s) of equipment used, the identity of every person present, the location of the client and clinician, and the type and rate of transmission.

It is the clinician’s role to ensure client confidentiality when telepractice services are used. In order to do so, clinicians must have knowledge of

Enlisting Stakeholder Support

When implementing a telepractice program, it is essential for practitioners to gain the support of stakeholders, including clinicians, administrators, sponsors/payers, technical and support staff, teachers, multidisciplinary team members, students and parents, and clients and family members/caregivers. Without mutual understanding, collaboration, and a receptive attitude toward telepractice on the part of all stakeholders, a telepractice program can fail.

Methods for enlisting support include

Employment in Telepractice

Telepractice may be one aspect of an institution’s or company’s services, or it may be the exclusive focus. Because telepractice is a relatively new area of service delivery, audiologists and SLPs have questioned how to determine whether a prospective employer provides appropriate training and support enabling them to deliver high-quality services.

The following are questions that could be explored by a potential telepractitioner:

Resources

ASHA Resources

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

References

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