20Q: A Decade of Teleaudiology Transformation and the Road Ahead

From the Desk of Gus Mueller

It was back in 2009, at the AAA meeting in Dallas, TX, when Jay Hall stopped me in the hallway (or maybe a bar) and suggested I attend his session the next day, as something "big" was going to happen—he was doing a session with an audiologist from South Africa, De Wet Swanepoel (more on him later). So, I did go, and indeed, something big did happen . . . at least for me. I witnessed an impressive live example of diagnostic teleaudiology. Using KUDUwave audiometric software, Jay conducted pure-tone audiometric testing (while we all watched on the big screen) on a woman located in a rural South African village, 8700 miles away. All went well—and yes, she did have a hearing loss. At that time, we had been hearing about teleaudiology for 10 years or so, but this was probably the first trans-Atlantic application.

As you probably guessed, the South African audiologist I mentioned, De Wet Swanepoel, is our 20Q guest author this month. This isn’t his first visit to these pages, as back in 2013 he did a review of a new emerging area of our profession . . . teleaudiology! He’s back this month to give us an update of the progress and advancements that have been made over the past decade.

De Wet Swanepoel, PhD, is professor in the Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa, and also adjunct professor at the Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine. He has published nearly 300 peer-reviewed articles, books and book chapters, and is funded by the NIH, UK Academy of Medical Sciences, National Research Foundation. Dr Swanepoel is former president of the International Society of Audiology and editor-in-chief of the International Journal of Audiology.

He is founder of a digital health company called the hearX group, with a focus to produce digital solutions across the spectrum of detection, diagnosis, and treatment of hearing loss. One of the group’s products, the hearTest Occ Health, was built around their digital audiometry application, and recently was named the Occupational Health & Safety new product of the year.

So what has happened in the area of teleaudiology over the past decade? In his excellent review, De Wet brings us up to date on synchronous vs. asynchronous applications, mHealth technologies, lessons we learned from COVID-19, the teleaudiology impact on affordable care, the emerging role of AI, and much more.

 

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: A Decade of Teleaudiology Transformation and the Road Ahead

Learning Outcomes 

After reading this article, professionals will be able to:

• Identify key advancements in teleaudiology and mobile health technologies that have shaped hearing healthcare delivery over the last decade.
• Evaluate the impact of COVID-19 on the adoption and perception of teleaudiology among professionals and patients.
• Describe how current teleaudiology practice and reimbursement policies and guidelines can be used to effectively integrate teleaudiology services into their practice.

De Wet Swanepoel, PhD

1. I’ve heard some different definitions of teleaudiology. What’s yours?

Teleaudiology? I like to think of it as the remote cousin of traditional audiology, using tech to bring hearing care right to your living room. Very simply, teleaudiology, a subset of telehealth, leverages telecommunications technology to deliver audiological services remotely, breaking the barrier of physical presence required in traditional care settings. Teleaudiology can be delivered in various modes, including synchronous services, where audiologists interact with patients in real time, and asynchronous (or store-and-forward) services, where interactions between the audiologist and patient do not occur simultaneously. Most teleaudiology approaches utilize a hybrid model that combines both synchronous and asynchronous services. You might recall that you and I talked about this topic here at 20Q about 10 years ago (See here). Since then, teleaudiology has grown in leaps and bounds. Beyond just advancements in tech, it's the shift towards integrating wellness and preventive care into our digital health strategies that's truly reshaped hearing health. This journey mirrors the technological and healthcare landscape shifts, with digital health carving out a broad category that encompasses teleaudiology, focusing not only on treatment but also on prevention and wellness in hearing health. This evolution isn't just about technology; it's also about a shift in focus towards wellness, preventive care in hearing health, and how we've adapted, especially under the spotlight COVID-19 shone on virtual health access. With mHealth's rapid advancements playing a pivotal role, teleaudiology has become key in making hearing healthcare accessible, comprehensive, and preventive, reflecting the changing landscapes of both healthcare and patient needs.

2. You mention mHealth—not something I’ve heard of. What is it, and how does it differ from telehealth?

The term mHealth, short for mobile health, is a subset of telehealth that specifically uses mobile technologies like smartphones and tablets to deliver health services and information. While telehealth encompasses a broad range of technologies and methods for delivering virtual medical, health, and education services, mHealth focuses on leveraging mobile devices to improve healthcare accessibility. It stands out for its portability, ease of access, and ability to offer personalized health interventions directly to users, making it a key player in expanding the reach of teleaudiology services.

3. How are mHealth technologies used in teleaudiology?

You can think of mHealth as the Swiss Army knife for teleaudiology—packed with tools that transform phones into mobile clinics, making hearing care accessible even in the most remote corners. These technologies can enable remote assessments, manage patient care, and provide interventions, making hearing health services accessible anytime, anywhere. It's about harnessing the power of mobile devices to keep the lines of communication and care open between audiologists and their patients. We recently did a scoping review of mHealth applications in audiology (Frisby et al. 2022a) which demonstrated a meteoric rise in applications over the years totaling close to 150 articles covering the range from promotion, screening, diagnosis, treatment, and support. The work specifically highlights their tremendous benefit in low- to middle-income settings where service access is dire.

4. COVID was a game changer for many industries. I suspect it also impacted teleaudiology?

COVID-19 didn't just change the game; it set new rules, making remote hearing care a necessity overnight. This shift has not only opened our eyes to teleaudiology's efficiency, but also fostered a deeper acceptance among both patients and professionals. The pandemic highlighted teleaudiology's potential to maintain continuity of care when in-person visits weren't possible, driving innovation and acceptance in the process. This transition not only demonstrated the effectiveness and efficiency of teleaudiology in maintaining audiological care but also significantly changed the perspectives and attitudes of both professionals and patients towards its use. The forced adoption led to a rapid familiarization with teleaudiology, highlighting its advantages in accessibility and patient engagement. Importantly, this period also saw increased regulatory support and reimbursement for teleaudiology services, addressing major barriers to its widespread adoption. This collective experience has established teleaudiology as a vital component of audiological care, paving the way for its continued integration into healthcare practices.

5. What teleaudiology lessons did we learn during COVID-19?

During COVID-19, teleaudiology rapidly adapted to continue providing care, highlighting the feasibility of remote hearing aid assistance, troubleshooting via videoconferencing, and the widespread adoption of remote adjustment and programming of hearing aids with industry support. Counseling and rehabilitation sessions transitioned smoothly to online formats. Challenges persisted with initial diagnostics and fittings, yet innovative solutions like drive-through testing and low-touch diagnostics emerged, alongside home self-test kits supported by telehealth (Swanepoel & Hall, 2020). The pandemic underscored teleaudiology's potential, driving innovation and exploring new service delivery methods.

6. Has the surge in teleaudiology adoption spurred by COVID-19 begun to diminish?

While the urgent push towards telehealth seen during the pandemic has normalized, the momentum for teleaudiology hasn't waned; it has evolved. The necessity-driven adoption has turned into a preference for many, as both clinicians and patients continue to appreciate the convenience, efficiency, and expanded access that teleaudiology provides. It's less about fading momentum and more about integrating these practices into a new standard of care. In some instances, the allowances from regulatory and reimbursement perspectives during COVID-19 have started to be removed which may well undermine some of the ground won during the pandemic.

7. With COVID behind us, why should we still be interested in teleaudiology?

Remember even as we step beyond the pandemic's shadow, the case for teleaudiology remains stronger than ever. The escalating prevalence of hearing loss globally, affecting 1 in 5 today and projected to impact 1 in 4 by 2030, (WHO, 2021), is already challenging traditional in-person service delivery models. In regions like Africa and South-East Asia, for example, there are less than 1 audiologist to every million persons (WHO, 2021). Even in the US, however, there is a major gap in accessible services with reported shortages of audiologists (Windmill and Freeman, 2019) due to an inadequate plateau in number of audiologists at around 13 000 (Windmill & Freeman, 2013). What exacerbates this is the inequitable distribution of audiologists who are much more likely to practice in metropolitan counties with higher median household incomes, younger populations, and lower proportions of older adults reporting hearing difficulty (Planey, 2019). This leaves us with an inverse relationship between audiologist availability and the need for hearing health services.

8. Can telehealth really support more affordable hearing care?

Absolutely. The conventional model of audiology, with its significant initial investment and ongoing expenses, struggles to scale effectively for broad hearing healthcare delivery. Rethinking our approach to include public health and consumer-driven frameworks allows us to tailor the care level directly to the patient's needs and the required specialist's involvement. Teleaudiology, empowered by new technologies, unlocks the potential for rapid, scalable services that can make hearing care more accessible and affordable without necessarily compromising outcomes. Think about it this way: While an audiologist can only see one patient at a time, a digital hearing health service can reach an unlimited number of people simultaneously. Take the official WHO hearing screening app, hearWHO, as an example. Available on Android and iOS, it expanded hearing screening access to nearly 250 million people across over 190 countries in its first two and a half years alone (De Sousa et al. 2022). That’s what I mean by rapid scalable service.

9. Can you provide a more private practice relevant example?

Sure. A more tangible example for clinicians is the use of the same screening technology on their practice websites to offer screening 24/7 that they can asynchronously review at a convenient time and schedule an appointment for those persons interested in leaving their details. In a study on this exact service, we found that more than 60% of persons using this asynchronous teleaudiology service did so outside of typical office hours, which demonstrates the advantage of an asynchronous telehealth solution like this (Ratanjee-Vanmali, 2020).

10. Screening is simple enough, I guess. How can telehealth technologies make other audiology services more available?

The technologies enable a more decentralized audiology model, something that has been foreign to audiological services since its inception. Audiology, traditionally, is a centralized, time-intensive, and expensive healthcare commodity. New, simple, robust technologies that also enable telehealth are, however, making it possible to reach more people at the levels of hearing care they require. Except for pediatric cases or complex hearing conditions requiring medical intervention, most hearing care services can now be efficiently provided outside traditional clinic settings, through innovative, user-friendly digital technologies. This shift adheres to the 80/20 principle, with 80% of adult hearing issues being manageable at the community level, leaving only 20% in need of specialized, clinic-based services. This evolution paves the way for more personalized, accessible, and cost-effective hearing care solutions, focusing on broader community access while preserving centralized care for those with complex needs.

11. Not quite following—can you give me an example of how this might work?

Sure. As a WHO Collaborating Centre for the Prevention of Deafness and Hearing Loss we partnered with the WHO to trial a community-based model of hearing aid delivery for adults in low-income settings. In this model, a trained community health worker provides the hearing screening and testing with remote asynchronous support from an audiologist. The technologies are all smartphone-based, including a low-cost digital otoscope and automated audiometer that facilitates the screening and characterizes the hearing loss. All the results are synced to a secure cloud-based portal where an audiologist can remotely check and make necessary recommendations. The approach here combines task sharing among specialists and trained non-specialists to facilitate hearing care services, enabled by innovative technologies, with training, surveillance, and remote support from audiologists. The WHO guideline documents have just been released and are freely available here (WHO, 2024).

12. What about the provision of hearing aids in this community-based telehealth model?

In previous work (Frisby et al. 2022b), we used low-cost hearing aids that can be fitted directly from the mobile test devices through Bluetooth connectivity according to the NAL/NL2 fitting algorithm with very good outcomes. For this latest WHO study, the recommendation is to use present hearing aids in low-income settings to ensure the models are affordable (WHO, 2024). But we use an mHealth acclimatization and support program that users get on their mobile phones or a significant other's mobile phone to guide them through the initial few weeks of adjustment, troubleshooting, and care of the devices. Furthermore, they can directly connect with the community health worker on text messages or calls for assistance and this CHW can escalate requests to the remote support audiologist as and when necessary. This program has already demonstrated significant benefit and widespread use and uptake (Frisby et al. 2023).

13. To be honest, I really haven’t done much work with teleaudiology in my practice. What do surveys say? Are most audiologists on board with this?

Surveys reveal audiologists are warming up to teleaudiology, especially post-COVID-19. Eikelboom et al. (2022) noted a jump in telehealth's importance from 44.3% before the pandemic to 87.1% during, with a similar rise in usage. Another survey by Chong-White et al. (2023) also emphasized this, showing increased use and benefits but also highlighted potential perceived challenges like reduced job satisfaction and difficulties in establishing client rapport. Despite hurdles like technology and training needs, the overall trend suggests growing acceptance and adoption of teleaudiology among audiologists.

14. What’s next for teleaudiology in terms of research and development?

Research in teleaudiology is poised to expand further, focusing on refining service delivery models, improving technology integration, and addressing remaining challenges like regulatory frameworks and reimbursement policies. We're likely to see more studies exploring patient outcomes, cost-effectiveness, and long-term sustainability.

15. What’s the role of artificial intelligence (AI) in teleaudiology?

Artificial intelligence (AI) holds significant promise in teleaudiology by enhancing diagnostic accuracy, personalizing treatment plans, and streamlining administrative tasks. AI algorithms can analyze large datasets of auditory information to assist in diagnosing hearing disorders and recommending appropriate interventions. AI-powered hearing aids are also being developed to adapt to individual hearing needs in real time. Additionally, AI can automate routine tasks, improving efficiency and freeing up audiologists to focus on more complex aspects of patient care.

16. Are there privacy concerns with teleaudiology and mHealth?

Privacy concerns are paramount in teleaudiology and mHealth due to the use of personal health information transmitted over digital networks. It's crucial for providers to adhere to strict data protection standards, such as encryption and secure data storage, to safeguard patient confidentiality. Compliance with regulations like HIPAA (in the US) or GDPR (in the EU) is essential to ensure patient privacy and trust in teleaudiology services.

17. How can teleaudiology contribute to global hearing health initiatives?

Teleaudiology has the potential to significantly impact global hearing health by overcoming barriers to access and affordability. By leveraging telecommunication technologies, audiologists can reach underserved populations in remote areas, providing essential hearing care services and education. Teleaudiology can support WHO initiatives to address the rising prevalence of hearing loss worldwide and promote equitable access to hearing healthcare.

18. What are the challenges hindering the widespread adoption of teleaudiology?

Several challenges hinder the widespread adoption of teleaudiology, including limited access to reliable internet infrastructure in rural areas, concerns about reimbursement and regulatory frameworks, and the need for specialized training among healthcare professionals. Additionally, some patients may prefer in-person interactions for certain aspects of audiological care, posing a barrier to full telehealth integration.

19. How can training and education in teleaudiology be improved?

Improving training and education in teleaudiology is critical to ensure competence and confidence among healthcare professionals. This includes incorporating teleaudiology into academic curricula, providing hands-on training with telehealth platforms, and offering continuing education opportunities. Collaborations between academic institutions, professional organizations, and industry partners can enhance the development of teleaudiology competencies.

20. What future trends do you foresee for teleaudiology?

The future of teleaudiology looks promising, with advancements in technology driving innovation in service delivery and patient care. We can expect continued integration of AI and machine learning, improved interoperability of telehealth systems, and expanded use of wearable devices for remote monitoring. Teleaudiology will likely play an increasingly central role in audiological care, providing personalized, accessible, and cost-effective solutions to meet the growing global demand for hearing healthcare.

References

Frisby, C., Mahomed-Asmail, F., Eikelboom, R. H., Kuper, H., & Swanepoel, D. (2022). mHealth applications for hearing loss – a scoping review. Telemedicine and e-Health, 28(8), 1090-1099. https://doi.org/10.1089/tmj.2021.0460

Frisby, C., Eikelboom, R. H., Mahomed-Asmail, F., Kuper, H., De Kock, T., Manchaiah, V., & Swanepoel, D. (2022). Community-based adult hearing care provided by community healthcare workers using mHealth technologies. Global Health Action, 15(1), 2095784. https://doi.org/10.1080/16549716.2022.2095784

Frisby, C., Eikelboom, R. H., Mahomed-Asmail, F., Kuper, H., Moore, D. M., de Kock, T., Manchaiah, V. M., & Swanepoel, D. (2023). mHealth hearing aid acclimatization and support program in low-income communities: A feasibility study. JMIR Formative Research, 7(1), e46043. https://doi.org/10.2196/46043

Chong-White, N., Incerti, P., Poulos, M., et al. (2023). Exploring teleaudiology adoption, perceptions and challenges among audiologists before and during the COVID-19 pandemic. BMC Digital Health, 1(24). https://doi.org/10.1186/s44247-023-00024-1

De Sousa, K. C., Smits, C., Moore, D. R., Chadha, S., Myburgh, H. C., & Swanepoel, D. (2022). Global use and outcomes of the hearWHO mHealth hearing test. Digital Health, 8, 1-9. https://doi.org/10.1177/20552076221113204

Eikelboom, R. H., Bennett, R. J., Manchaiah, V., Parmar, B., Beukes, E., Rajasingam, S. L., & Swanepoel, D. (2022). International survey of audiologists during the COVID-19 pandemic: Use of and attitudes to telehealth. International Journal of Audiology, 61(4), 283-292. https://doi.org/10.1080/14992027.2021.1957160

Manchaiah, V., Hall, J. W., Beukes, E. W., & Swanepoel, D. (2023). Teleaudiology Today: Remote Assessment and Management of Hearing Loss. Amazon Publishing.

Ratanjee-Vanmali, H., Swanepoel, D., & Laplante-Lévesque, A. (2020). Optimizing audiology websites to increase patient reach. The Hearing Journal, 73(7), 31-33.

Swanepoel, D., & Hall, J. W. (2020). Making audiology work during COVID-19 and beyond. The Hearing Journal, 73(6), 20-24.

Windmill, I., & Freeman, B. (2013). Demand for Audiology Services: 30-Yr Projections and Impact on Academic Programs. Journal Of The American Academy Of Audiology, 24(5), 407-416. 

Planey, A. M. (2019). Audiologist availability and supply in the United States: A multi-scale spatial and political economic analysis. Social Science & Medicine, 222, 216-224. https://doi.org/10.1016/j.socscimed.2019.01.015

World Health Organization. (2021). World Report on Hearing. Retrieved from https://www.who.int/publications/i/item/9789240020481

World Health Organization. (2024). Hearing aid service delivery approaches for low- and middle-income settings. Retrieved from https://www.who.int/publications/i/item/9789240087927

Tao K, Swanepoel D, Brennen-Jones CG, Jayakody, DMP, Moreira T de C, Coetzee L, Eikelboom RH (2021). Teleaudiology hearing aid fitting follow-up consultations for adults: a single-blinded crossover randomized control trial and cohort studies. International Journal of Audiology, 60: S49-S60. https://doi.org/10.1080/14992027.2020.1805804