Telepractice in Audiology

Overview:

The 1990's was a decade of significant advancement in computer technology. Personal computers developed into powerful, integrated systems. Internet applications evolved from simple e-mail communication into sophisticated web site offerings providing complex, high-tech audio and video information streaming.

Not surprisingly, recent advancements in computer and interactive video technology have resulted in greater use of Telepractice--the provision of health services from one location to another using an electronic medium. Clinicians and researchers frequently use the term "telepractice" (rather than "telemedicine" or "telehealth") because the term connotes broad-based involvement by health professionals. Congress supported the notion of comprehensive health care services from a distance by passing the Comprehensive Telehealth Act of 1997 that promoted allied health professional involvement in telepractice.

Current Applications:

The authors believe that "face-to-face" interaction will always be the most desirable form of service delivery for audiologists. However, for any number of reasons, "face-to-face" encounters are not always possible or feasible. As such, consumers in rural or isolated areas can receive appropriate health care services through telepractice media. While this claim may be startling, the reader should recognize that telepractice has been steadily adopted during the last decade in many professions including cardiology, radiography, otology, pharmacology, psychology, psychiatry, and other health fields (Nickelson, 2000; Perednia & Allen; 1996, Stamm, 1998).

Telepractice services are typically provided using relatively simple technology such as telephone conferencing, faxing, or e-mail. In fact, many audiologists already engage in telepractice when they provide online or over-the-phone services.

Certainly, telepractice can be much more sophisticated. For example, some telepractice systems utilize video otoscopy and other hearing services over wide area networks using high-speed "point to point" connections and premium interactive video systems. These systems are capable of providing essentially real-time images of the consumer/patient and high-resolution video otoscopy data.

Regardless of the technology or sophistication used, the overall goal in telepractice is to bridge service gaps in rural or underserved areas. While audiology as a profession has been slow to adopt telepractice, this form of service delivery is becoming more feasible and practical as the availability of inexpensive interactive video systems evolves.
Another factor related to this growth certainly has been the availability of governmental funding to develop telepractice programs in many states. Additionally, telepractice service providers are receiving reimbursements at higher levels due to new funding guidelines enacted in the fall of 2001 (Deb Lamarche, personal communication, January 24, 2002).

Some audiologists have already been successful in providing services to distant or rural locations using telepractice (Krumm, Marincovich, Hogarth, Martin & Windsor, 2001). In general, audiology telepractice programs have been implemented to increase hearing services in isolated areas. Audiology telepractice services to these areas normally utilize "store and forward" ( a process in which data in various formats are stored for subsequent rather than real-time transmission). Additionally, interactive video has been commonly used.

However, at least a few centers have examined solutions that enable the audiologist to evaluate patients/clients using remote control computer software. If successfully engineered, systems of the future may permit an audiologist to administer hearing services similar to those provided in a typical audiology clinic. Regardless of how the technology evolves in the future, right now, telepractice systems permit audiologists to provide some hearing tests, aural rehabilitation, hearing aid adjustment, counseling, and personnel training. In addition, it may be possible to administer some vestibular testing or cochlear implant programming using telepractice.

Models of delivery of services:

Preliminary projects and research suggest that there at least two effective telepractice models which might be effective for audiologists.

The first model requires the use of a trained audiology technician at the remote site. In this model, the technician would conduct hearing testing under the direction of an audiologist who supervises the technician and observes client/patient responses using interactive video. Marincovich successfully practiced audiology using this approach for two years in northern California in one rural community (Krumm et al., 2001). In many ways, Marincovich's model was ideal as it was provided using a high-speed wide area network, quality interactive video, and a highly skilled technician (certified as an audiology technician and hearing aid specialist by the state of California).

Krumm et al. (2001) suggested that another audiology telehealth model might include using interactive video, computer remote control capabilities, a high-speed network, and "off-the-shelf" audiology peripherals. In this particular model, a trained assistant at the remote site prepares the patient for the test procedures e.g., by correctly placing headphones or electrodes. Subsequently the audiologist, at a distant location using a computer, directly tests the patient/client. As many audiology systems (audiometers, otoacoustic emission systems, and auditory brainstem units) are essentially computer peripherals, hearing testing may be accomplished with surprising ease with the practitioner actually doing the testing.

Research:

Researchers at Utah State University, Utah and at Minot State University, North Dakota have successfully tested this telepractice model over a high-speed network as well as over the Internet. While the preliminary outcomes of this method have been encouraging, validation of this paradigm will require further evaluation. Unfortunately, the science of telepractice technology is new to audiology and few studies exist to validate its use. Therefore, it is not possible to know how telepractice can be used most effectively. Nevertheless, preliminary research and field-initiated projects have provided encouraging data supporting the use of telepractice. Perhaps in the future, telepractice may serve to alleviate personnel and consumer problems associated with rural audiology programs. Telepractice may also offer rural consumers continuity of services, a high level of professional expertise, up-to-date information, and a family- oriented system (by reducing travel costs and lost wages).

Summary:

Audiologic services provided through telehealth technology may provide a solution for service "gaps" in rural areas. Using telehealth technology, audiologists in metropolitan areas could offer sophisticated hearing tests to infants, children, and adults in rural communities. An effective audiology telehealth system could further promote a family-friendly atmosphere as well as continuity of services.

Researchers have yet to publish data evaluating the validity of telehealth technology for hearing assessment. Clearly, further research is warranted to validate telehealth technology in Audiology and to determine its' possible applicability. Unlike many of the present day studies describing telepractice services in other disciplines, rigorous research principles must be applied in future research projects to insure quality audiological consumer services.

While there are many yet unresolved issues related to telepractice, we now have a window of opportunity for audiology to take the initiative in exploring a path that may lead to expansion of our scope of practice and helping us establish and maintain the autonomy which we continually seek.

References:
Comprehensive Telehealth Act (1997). Retrieved February 1, 2002.

Krumm, M., Marincovich, P., Hogarth, B., Martin, L., & Windsor, T. (2001). Providing audiological services through a telemedicine medium. Paper presented at the meeting of the American Academy of Audiology, San Diego, CA.

Nickelson, D. (2000). Telehealth and the evolving health care system: Strategic opportunities for professional psychology. Professional Psychology: Research and Practice, 29, (6), 527-535.

Perednia, D., & Allen, A. (1996). Telemedicine technology and clinical applications. JAMA, 273, (6), 483-488.

Stamm, B.H. (1998). Clinical applications of telehealth in mental health care. Professional Psychology: Research and Practice, 29, (6), 526-542.

For further information contact Mark Krumm, Ph.D., 435-797-0946 mkrumm@coe.usu.edu or John Ribera, Ph.D., 435-797-7190 jribera@coe.usu.edu.
Watch for telepractice roundtable and discussion at AAA in Philadelphia this April.