20Q: Teleaudiology - The Future is Now

From the Desk of Gus Mueller

You regular 20Q readers might recall that back in October of 2013, Dr. De Wet Swanepoel visited this space, and talked about the latest developments in teleaudiology.  De Wet gave us a great overview of the international picture, but a lot is happening in teleaudiology right here in the U.S.  And, a lot of progress has been made since De Wet’s article of 5 years ago.

An organization at the forefront of this innovative method of hearing care is the Department of Veterans Affairs.  And the person who has been leading the charge for the VA for the past several years is our 20Q guest author this month.  Chad Gladden, AuD is the Audiology Telehealth Coordinator for the VA Audiology and Speech Pathology National Program Office.

Perhaps Dr. Gladden’s interest in telehealth stems from his upbringing in the rural area of Bismarck, North Dakota; home to NFL MVP-caliber quarterback Carson Wentz, the reigning Miss America Cara Mund, and the fledging Editor of this AudiologyOnline 20Q column.

Chad states that in his career, while serving at the Department of Veterans Affairs in Maryland and Wisconsin, as a clinical audiologist, supervisor and program manager, he was drawn to innovations that were occurring within the field. He was introduced to teleaudiology delivery models that established greater convenience, access, and connections for Veterans and caregivers.  For his continued efforts, he has been honored with the Association of VA Audiologists Innovation Award.

Through his many publications, presentations and workshops, Dr. Gladden rapidly has become one of the go-to guys on the topic of teleaudiology for both professional organizations and clinicians.  We are fortunate to have him stop by 20Q to update on what is happening is this exciting area.

Gus Mueller, PhD
Contributing Editor

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

20Q: Teleaudiology - The Future is Now 

Learning Outcomes

After this course, readers will be able to:

• Define teleaudiology and explain the rationale for offering teleaudiology services.
• Describe some potential challenges of offering teleaudiology based on the Department of Veterans Affairs (VA) examples provided.
• Explain some key considerations for getting started with teleaudiology.
• Discuss some ways that the VA has implemented teleaudiology, including services provided, and outcomes.  

      Chad Gladden

1. Has “teleaudiology” now become the accepted term for our remote patient care? 

It has, but there are other more general terms, as well. We often see the terms telehealth, virtual care, and connected health used interchangeably. In theory, they are the same, but it is often easiest to think of it like this: Telehealth generally focuses on the use of telecommunications technology (videoconferencing, imaging, home monitoring, etc.) in direct patient care. Connected health is both a concept and a comprehensive, patient-centered delivery model. It has been used to describe the provision of direct patient care, but has a broader scope that includes health care informatics/analytics, integration with the Electronic Health Record (EHR), mobile technologies/apps, secure messaging, and other services. Virtual care is an umbrella term for all things “tele, mobile, connected health.” It infers that care is a modality that does not occur in a traditional "face-to-face" encounter and the provider and patient are distantly connected.

Disciplines use the prefix tele- (e.g. teleaudiology, telespeech, telerehabilitation) to suggest that care is provided by a modality other than one used for face-to-face services or use of technology to serve patients where services are not available or completed in a remote format.   

2.  Why has it become necessary to offer “services at a distance” for patients?

My experience has been in the Department of Veterans Affairs (VA), but need for this service is widespread. Telehealth, specifically teleaudiology, is a not a new concept but has gradually become an increasingly important service delivery medium. Among the drivers for innovation and teleaudiology is a systems-wide focus that places the patient in the center of care, with technological advances supporting those efforts. In practice, this means that patients have more effective connections with providers, have greater choices in the format for care delivery, and can improve their access to care without sacrificing quality. Due to the known travel time and costs that many rural patients experience, teleaudiology offers a clear option to traditional face-to-face care. It is also important to note that teleaudiology is not limited to rural patients and can be an effective service to those in urban areas, as well. Patient outcome data collected over several years show that satisfaction with teleaudiology is the same or better than traditional office visits.   

3.  Is teleaudiology effective for urban dwellers too?

Yes, most certainly.  We have examined not only driving distance, but driving time, parking, and other coordination challenges patients and caregivers experience in maintaining scheduled appointments.  We learned that many of the smaller Community-Based Outpatient Clinics (CBOCs) were significantly easier to access than the large urban facilities and, consequently, many patients in urban areas have chosen teleaudiology services as their preferred delivery system. Additional access points provided by the CBOCs have proven to be beneficial not only for the urban patients, but also their caregivers who often travel with them. 

4.  What are some of the obstacles that you have experienced in advancing teleaudiology?

The obstacles to providing teleaudiology vary and are related to patient, facility, and provider issues. Among the forces for successful implementation are clinician/provider, patient, and facility staff buy-in. This requires that individuals wishing to be involved in teleaudiology service delivery embrace the modality, its changes, and the possible discomfort that are inherent in its early implementation. For some audiologists, providing traditional face-to-face care is what they know best, and teleaudiology requires a significant transition, including learning new ways of providing care. For some patients, traditional care is the only one they have experienced and they sometimes fear a decrease in the quality of care and a different care environment.

In addition to potential obstacles facing audiologists and patients, the process for establishing teleaudiology services is complex and requires facility staff to undertake tasks of coordination, team building, and an accurate assessment of community and facility needs, resources, and partnerships. Many facilities are initially excited about implementing the services, but don't fully understand the critical importance of “front-end,” preparatory activities such as establishing strong channels of communication between and among information technology staff, biomedical engineering, facility leadership, and support personnel. Planning and on-going evaluation takes time and effort but, when done well, yields significant benefits to patients and staff. 

5.  Who are the typical key members of the teleaudiology team? 

From a clinical standpoint, it is important to have a “clinical audiologist champion” or a properly trained audiologist to assume a consistent, reliable leadership role in moving services forward. That person may also be serving as a Service Chief, a supervisor, or a staff member. There may be several clinical audiology champions at a facility, depending on the size and maturity of the program.

In addition to the clinical audiology champion(s), it is necessary to have a facility telehealth coordinator (FTC) or a formally designated staff member who oversees the telehealth services that are offered. If a designated FTC is not available (i.e. small practice), the audiologist-champion may assume this role with additional training specific to telehealth delivery. The individual providing oversight needs to ensure that a service agreement and an emergency plan are established and that there are providers, equipment, space, key infrastructure components, and other accessible resources in place. The FTC also works with the clinical audiology champion(s) to establish work flow processes that are clear and effective.

In addition to audiology providers and a designated telehealth coordinator, IT and bioengineering staff work together to ensure that equipment is available and operating properly. Their responsibilities range from providing oversight of videoconferencing equipment to the managing audiology-specific hardware and software. 

In a facility where audiology has not been offered before, getting the support and buy-in from the clinical managers and facility leaders is critical to ensuring that all components of the service are coordinated before full implementation—such things as patient check-in processes, proper triage procedures of audiology patients, and ensuring the proper sound environment exists for audiology care. The latter is particularly important in clinics without sound room enclosures.

Support personnel (telehealth clinical technicians/audiology assistants) serve as critical links in preparing for and assisting with patient encounters, and coordinating follow up care. Their initial and on-going training is a significant part of planning for high quality teleaudiology care.  Technicians need to have a working knowledge of audiology services, the set-up of equipment, patient preparation procedures, and the proper scope and role in working with the remote audiologist.

6. What are some of the teleaudiology services currently offered?

You might be surprised by the range of services we offer at the VA. Teleaudiology includes group aural rehabilitation and tinnitus classes, hearing aid fittings, aftercare services, and remote diagnostic testing. There are also pilots underway, or recently completed, that are demonstrating remote programming of cochlear implants, the use of video and mobile technology to make hearing aid programming adjustments in the home, and automated pure tone hearing testing.  

7. Regarding diagnostic testing, what about those patients who may have relatively normal pure tone thresholds, yet experience notable difficulty understanding speech in noise? 

Ideally, we would like to offer a wide range of tests of hearing function. The problem of “hidden hearing loss” as a result of synaptopathy, secondary to noise trauma, certainly is receiving attention lately, and it is a problem that is becoming a focus of our care and research. Accurate assessment of an individual beyond standard, basic audiometric tests to predict performance in real-world situations is challenging. Speech in noise tests can be done remotely and are an option for audiologists with standard audiometric setups. The VA has taken a systematic approach to the way remote diagnostic testing is done to ensure that there is consistency in the testing environments within different facilities. Considerable time has been taken to investigate best practice protocols and transducer types that are best suited for the remote clinics. 

8. What if the initial diagnostic findings show unusual ear asymmetry or some other red-flag finding - what happens then?

Emergency planning and standard operating procedures need to be included that mirror those best evidence practices used in traditional face-to-face services. If unusual ear asymmetry or other red-flag findings are noted during evaluation, the patient should be referred to the associated medical center for further assessment by ENT or other disciplines, if care cannot be received on-site. In some cases, travel may be a significant barrier and the clinic may have an agreement in place for care to be provided by a local provider. This is something that should be formally outlined in a telehealth service agreement or some other means designating the appropriate course of care.

9. Do you utilize audiology assistants for the remote patient care, or is it all done through contact by phone or Skype with an audiologist?

Teleaudiology, and telehealth in general, view support personnel as integral to the delivery of connected-care. The utilization of well-trained support personnel in various telehealth delivery models adds both efficiency and quality to the care provided. Telehealth clinical technicians (TCTs) work closely with audiologists to prepare for patient visits, assist with specific tasks during the encounter, and serve to reinforce important hearing care patient education. Currently, we are seeking effective ways to extend care into the home by a video and data connection using a patient’s smart-based device and downloaded app or web secure portal to program their hearing aids. Increased utilization of telephone care is also a priority, and a long-standing component of audiology service delivery.

10.  What is the training time and qualifications for teleaudiology support personnel?

The training for teleaudiology is not just for support personnel, but for audiologists as well.  We have a core set of training modules that is required for all members of the telehealth teams. The content includes planning, set-up, and communication with patients, in addition to familiarization with selected equipment and processes. There are also additional specific virtual training requirements for audiologists. Once the online modules are completed, the team members are required complete a skills assessment proctored either face-to-face or virtually by an audiology master preceptor or an educational specialist from a national training center. More specific to your question, for support personnel, we require shadow experiences with a minimum of three to five days observing and demonstrating procedural competence within the work flow of the clinic. Acquisition of minimum skills for testing procedures, video-otoscopy, and similar skills requires one to two weeks of training, depending on the clinical background of the individual.

11.  What kind of group services do you provide?

Group aural rehabilitation or informational counseling is easily utilized with the multi-point video connections to various locations. Inclusion criteria is often determined by audiologist who is overseeing enrollment into the rehabilitation or educational setting. Sometimes, the audiologist conducting group telehealth services may be different from the person making the referral, particularly if that individual has a focus in aural rehabilitation or tinnitus. They too, will be required to have general training in telehealth delivery and learn procedures related to video connection(s), camera control, lighting/environment, and how to properly display patient education materials and other resources. Other disciplines, such as mental health providers, may participate in some of the group services. Progressive Tinnitus Management (PTM) is a model that the VA uses for Veterans with tinnitus and is an effective model in a group video format.

12. Do you use teleaudiology for the initial hearing aid fittings, or only for follow-up visits?

Initial fittings and follow-up visits are both done via telehealth. Generally, there is some face-to-face interaction that needs to occur, as well as gaining verbal consent for the services, whether that is for an initial fitting or for subsequent programming adjustments. We strongly encourage the remote audiologist provider and on-site support personnel to have a general sense of workflow and be able to work seamlessly with one another in either situations. Generally, initial fitting appointments will require more onsite instruction with the patient and technician/assistant who are essentially serving as supervised ‘hands’ for the appointment. The technician will model proper insertion/removal techniques, physical manipulation of the hearing aids, and highlighting various topics that are either verbally instructed by the audiologist through videoconferencing unit and/or shared content that is also sent home with the patient.  

13.  What if the patient needs post-fitting programming adjustments?

This indeed is something we do via teleaudiology. Programming adjustments are completed with a remote sharing application whereby the audiologist ‘takes-over’ the PC at the physical location where the patient is receiving care. With the support of a trained technician to prepare the patient for the visit, the audiologist will then also have the capability to conduct probe-microphone measurements to verify objectively programing changes.  Video capabilities and various peripheral cameras allow the audiologist to monitor the adjustment process. 

14. Although teleaudiology is convenient for your patients, doesn’t this service require additional staff coordination and infrastructure?

To begin the intensive process of providing teleaudiology services, facility staff at all levels must believe that there will be a reasonable benefit/return on their investment; one that requires fiscal commitment, human resources, physical accommodations, and an outlay of time and energy. Feedback from facility leaders and staff in locations that have successfully implemented teleaudiology services and received the gratitude of Veterans, would say that the investment was worth the effort.

Care coordination is, by far, one of the most significant challenges in teleaudiology care delivery, given the diverse staff that needs to be working together while being separated by distance. On-going, accessible staff training and inter-staff communication are essential to the initial start-up and longer-term sustainability of the teleaudiology program. Clear expectations for accurate and consistent technical set-up and contingency planning need to be addressed.

One important reason that teleaudiology works well for the VA is that we have had the infrastructure support and notable staff expertise in telehealth delivery for some time. Telehealth is not limited to the VA, however. An increasing number of private sector medical facilities have observed the growth of telehealth and its potential for improving access and quality of hearing care in everyday interactions with patients.  

We rely on biweekly calls and meetings, quarterly forums and continual communication to keep the program running efficiently.  This involves internal training, as well as involving vendors for specific training on the software and equipment.

15.  Has the teleaudiology process improved productivity?

In our evaluation of staff productivity, we have uncovered several misconceptions regarding telehealth or virtual/connected care. For some staff, it is seen as less than the "optimal" face-to-face encounter and it isn't “productive” because it requires additional effort for the provider to achieve increased patient convenience. It is sometimes viewed as a novelty, although at its core, teleaudiology is an integral part of a systems redesign effort that enhances our service delivery model and helps connect patients to providers in ways that are patient-focused, convenient to time and place, and of high quality.

Increased staff productivity is more evident in group aural rehabilitation and informational classes offered through telehealth. A group format through a video connections medium has also been a useful tool for tinnitus sessions. This format allows a single subject matter expert, such as an audiologist, to provide educational and informational content to multiple sites allowing other audiologists within the same system to continue providing patient care to other patients. Sites that have successfully become more efficient are generally those where there are strong working relationships among leadership staff, the provider working multiple sites, and support staff. 

We have learned that most audiology services can be effectively provided at the smallest or most remote, community-based outpatient clinic.  After initial staff training, service implementation, and staff workflow is stable, there is a significant opportunity to improve efficiencies. The use of a support personnel to provide room and equipment preparation, assist with selected aspects of hearing care, and reinforcement of patient education materials has a significant, positive impact on the audiologist’s productivity.

Some clinics utilize teleaudiology in an "open access" type format where teleaudiology visits and face-to-face care are balanced throughout the day to meet demands regardless of location. We are also in the process of implementing asynchronous models with automated audiometry that can also offer additional assistance in monitoring hearing or routine follow-up procedures. This will help in triaging care and ensuring staff work to the full scope of their licenses.

16.  How have your patients accepted the option of distance services? Has there been growth in utilization?

Veterans have generally been accepting and highly satisfied with our services. It is the patient experience with telehealth that has driven the rapid growth in teleaudiology care we have seen to date. Outcome data and anecdotal feedback from providers, patients, and families indicate that there is a population of Veterans for whom virtual care is be best kind of care in many situations and will become an expectation. In fiscal year 2017 alone, VA audiologists completed over 34,000 teleaudiology encounters to more than 21,000 Veterans.   

17.  What has the addition of teleaudiology services done for access?

Teleaudiology is one of the patient-driven services the VA has been using to improve access for all Veterans. It has allowed higher-level providers working with multiple sites to extend the scope of services and bring high quality hearing care closer to meeting individual patient needs and preferences. Improved geographical access and less transportation stress are clear benefits for many. The store-and-forward telehealth model also has a significant potential to improve access by allowing asynchronous review of automated hearing tests.

18.  You use the terms “store and forward” and “asynchronous review?”  I need some help with your lingo.

Store-and-forward telehealth is the use of technologies to asynchronously acquire and store clinical information (such as data, images, sound files, video files) that is then forwarded or retrieved by a provider at another location for clinical evaluations. The VA’s national store-and-forward telehealth programs operationalize this definition to cover services that provide this care using a clinical consult pathway and a defined information technology platform to communicate the event/encounter between providers, as well as enabling documentation of the event. Two of the more common uses for SFT is for teleretinal imaging for screening of diabetic retinopathy and teledermatology. Both of these specialties have the ability to schedule a patient at a remote location, have a trained technician take an image of the respective area, and the images reviewed by a clinician and impressions are rendered. The request, the report, and the image(s) are all stored in the electronic medical record.

For audiology, we have followed the same national pathways and information technology platforms used in VA.  The image(s) or audiology study is a PDF of an automated hearing evaluation (air conduction/bone conduction thresholds (masked)----closed set speech can also be included--- and images of external auditory canal, tympanic membrane, and pinna (w/receiver-in-the canal measuring tool) that are forwarded to a “master” audiologist with appropriate privileges who will review the study and make the appropriate clinical recommendations. There are also various performance indicators to determine the validity of the automated hearing test and exciting ‘marriage’ of audiology and telehealth technologies.

19.  I guess the most important question is how do the teleaudiology outcomes compare to direct face-to-face services?

You’re right, that is very important. Our standardized outcome measures, patient and provider satisfaction surveys, and other objective comparisons have consistently revealed and overall appreciation for teleaudiology services. The outcomes strongly reflect the positive attitude of quality staff who have worked diligently to create comfortable, efficient, and caring telehealth environment for their patients.

The VA Audiology Program has adopted the International Outcome Inventory for Hearing Aids (IOI-HA) as an outcome measure for its national hearing aid program. There is a breakout area within the database to designate whether care was received in a traditional face-to-face format or through a teleconnections medium. Currently, there have been approximately 7,000 completed IOI-HAs analyzed for teleaudiology. Data show that care delivered via teleaudiology was identified as good as or better than, traditional face-to-face encounters. There is also a breakout teleaudiology section on the national Clinical Video Telehealth Patient Satisfaction Survey that is randomly administered twice a year for all telehealth programs. This questionnaire, approved through the Office of Management and Budget, has yielded over 1,300 completed teleaudiology surveys with findings indicating a high level of satisfaction with care.

20.  So it sounds like the future of teleaudiology really is “now.”

We have worked diligently to make connected hearing care a reality for patients and their caregivers within the VA and have shared our work nationally and globally. Given the vision and recent advances in hearing care technology and the commitment of hearing care providers across the country to pilot projects and to innovate, the future for teleaudiology and telehealth in general is filled with hope and continued confidence.