Interview with Anne Simon, Au.D., Senior Pediatric Audiologist, UC Davis Medical Center
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Topic: Testing Infants Across the Miles - New Teleaudiology Program in Northern California
CAROLYN SMAKA: Today I'm speaking with Anne Simon, Au.D., an audiologist at UC Davis Medical Center in Sacramento, California. Our topic is a new teleaudiology program they've implemented to follow up with newborns who fail hearing screenings in rural areas of northern California. Anne, how did the program get started?
ANNE SIMON: We were approached by an audiologist at California Children's Services (CCS) because the lost to follow up rate for newborns who fail hearing screenings in rural Northern California is very high at about 40 percent. The babies who fail the newborn hearing screening in this area were not returning for follow up. And so CCS was looking for a way to help these families receive diagnostic evaluation.
There is a very large expanse of California that's north of Sacramento and extends north to the border of Oregon. Even people who live in California don't realize just how large a portion of the state this is, and how far it is away from Sacramento and the Bay area.
SMAKA: Why was the lost to follow up rate so high in this area?
SIMON: Infants were being screened and re-screened at their birth hospital, and when they didn't pass their screenings, they were told they would have to drive to Sacramento or to the Bay Area for a diagnostic audiology evaluation because there were no providers close to home. Many parents were simply not going, for various reasons. For families in the most remote areas, this might mean an 8 or 9 hour drive one way.
SMAKA: It's understandable how trying to make that trip with a newborn would be a barrier to follow up.
SIMON: Exactly. With a newborn, you would have to stop every couple of hours to feed them, and you may have a day or two off of work. It would be almost impossible to make it round trip in one day, so you may have to incur the cost and inconvenience of an overnight stay, while possibly trying to make arrangements for care of other children, as well. Logistically, it would be very difficult for most families of a newborn.
SMAKA: And we know how hard it is sometimes to impress upon parents about the critical time period we're working with when it comes to hearing loss in infants. If the infant is otherwise healthy, they may not understand how crucial the timeliness of follow up is.
SIMON: Right. Sometimes, as the months went by and the child got older, the parents would notice that the child would be responding to sound and then they would think an evaluation was not necessary. Or, by the time the child would make it in for an evaluation, the child would be several months old and then you could no longer get them to sleep for the ABR. They would have to be evaluated behaviorally, which we all know has its own challenges, not the least of which is that it often takes several appointments, delaying identification.
At UC-Davis Medical Center here in Sacramento, we do a lot of telemedicine. So we partnered with the State of California to develop a program utilizing telemedicine for these infants. The program is funded by a grant from the Maternal and Child Health Burreau at HRSA through the California Department of Education and Health Care Services.
We developed the program with audiologists at California Children's Services and then we chose a site in Redding, California, which is centrally located and one of the largest communities within the area we were looking to target in Northern California. At Mercy Medical Center in Redding we found two wonderful EKG/EEG technicians to work with us. The infants to be tested go to Mercy Medical Center where one of the techs prepares the child for the diagnostic evaluation. The technician then stays with the child and parent throughout the testing, and I perform the test and run the equipment remotely from UC Davis Medical Center in Sacramento.
SMAKA: Where did you get audiology equipment that can be used for remote testing?
SIMON: Any equipment that is PC-based can be used remotely if you have the right software to set it up as well as a secure Internet connection that will safeguard the patient information. All the testing equipment including ABR, ASSR, immittance, OAE and video otoscopy, is equipment generally used in an audiology clinic. We did end up purchasing equipment for this program because we needed equipment at Mercy Medical Center with the baby.
You can think of our teleaudiology program like this. When you have trouble with your computer, you may contact your IT department who then logs in and takes over your computer. They take control of your computer remotely and you sit there and watch them on your monitor as they fix your problem. That's what I'm doing when I test the infant remotely. The audiological equipment is at Mercy Hospital in Redding with the baby, the technician, and the parent. I run a second computer in Sacramento that controls the computer that's in Redding with all the audiological software.
SMAKA: This is amazing. When did this program start and how many infants have been tested remotely?
SIMON: Our first patient was seen in early December, and we've tested three children so far. Things have gone really well. We have an amazing team that includes a researcher and a great IT team. They were instrumental to setting up the connection and the technology, and solving any issues that have come up along the way.
SMAKA: As an audiologist, how does remote testing compare to traditional in-person testing?
SIMON: Although I have a high quality camera with great zoom capabilities, I can not see as much as I can in person. We move the camera stand and the parent's chair often throughout the session so I can see what I need to. I have found it works best to complete testing on one ear and then switch to the second ear instead of the more traditional manner of moving between the ears throughout the ABR evaluation. Tympanometry is taking more time than it would in person. It takes more time to obtain a good probe fit and the equipment is slower through the remote connection. The evaluations are taking more time in general. This is in part because the equipment is new and in part because I am training the technicians to perform the tasks that I normally do.
With two of the children we were able to complete the testing in two sessions, and with the third child we are going to need a third session. Our goal is to get all the audiological information that is necessary to move forward with intervention, whether that means a hearing aid fitting, early intervention, medical follow-up, etc.
As we were developing the program, we talked to other similar programs around the country, so we knew as well as we could what to expect and what we're finding is that remote testing takes a little more time. I find that if I see an infant in person and there is some degree of hearing loss, I often need two sessions to get everything I need and to start towards intervention. Part of the reason remote testing takes a little longer is because we are a new program and had some minor issues like trouble printing tympanometry results. Part of it is simply due to the nature of remote testing. For example, instead of looking at the infant's ear directly in person, I am instructing the technician at the other end where to move the camera, i.e. "Okay, I have viewed that part of the ear now move around to the other side." I do believe that as we get more experienced with it there will be less of a time difference as compared to in person testing.
SMAKA: Yes, it seems to me that even when you are working with new equipment with the patient in person, or in a new treatment room where your equipment or tools are different, the appointment may take more time.
SIMON: Yes, it is expected and it improves with familiarity.
SMAKA: What have the parents or caregivers reactions been? Have you gotten their feedback?
Infant Jack James rests in his mother Michelle's arms while undergoing audiology testing via a telemedicine arrangement between Mercy Medical Center, Redding and UC Davis. The patient is in Redding, California and the audiologist is in Sacramento, California. Photo credit: UC Regents.
SIMON: Yes, their feedback is important to us. All three sets of parents have been very pleased that they've been offered to participate in the program. They've all been very pleased that they didn't have to travel. Two of them have no prior experience with having a diagnostic evaluation like this so to them, this is normal. They are very happy to know their child is receiving the necessary evaluation that he or she needs.
When the child fails the hearing screening, the parents are given the option of an in-person diagnostic evaluation in the Bay Area or Sacramento, or via this teleaudiology program. I imagine that once they hear they can do this close to home they're interested to know that they have a choice.
In addition to the diagnostic component of this program, there is also a research component, and the families that participate in the diagnostic testing also agree to participate in the research.
SMAKA: What are you looking at in terms of research, the teleaudiology component?
SIMON: We know that ABR can be done remotely;there's been previous research that shows it can be done accurately. Instead, we're looking at patient satisfaction. We are also interested in the audiologist's perspective - does the audiologist feel that we're providing a sufficiently appropriate evaluation for the child? We are looking at the evaluation in its entirety - ABR, ASSR, and all the other diagnostic testing. We are looking at factors such as timeliness, determining if we are meeting our goal of identification by 3 months of age, and looking at outcomes.
SMAKA: You mentioned that in designing this program you connected with other teleaudiology programs?
SIMON: Yes, The audiologists at California Children's Services connected with the other programs to share information in order to help design a program that would be most successful. Four other facilities received the same grant that we did, and so, an audiologist with CCS, was communicating with them every few months to find out how they were doing, what their challenges were and sharing our experiences.
And then also, our technology team was communicating with people on the technology side of the other programs to make sure we were on the same page in terms of our connections. Everyone that is involved in teleaudiology now - whether it's here at UCD, in another State, or internationally - is a trailblazer. Teleaudiology is new for everyone, so it's wonderful when people can talk with each other, share information and learn from one another.
SMAKA: We know that counseling is extremely important as you need to help parents with their journey and also facilitate moving them to the next steps. How has counseling remotely been for you as an audiologist as opposed to counseling in person?
SIMON: It was one of my primary concerns going into this. All pediatric audiologists have had to tell parents that their child has hearing loss and we know how difficult that can be for the parent. Now envision telling a parent that their child has hearing loss when you're not in the room with them.
We did a few things to help make this work. First of all, we have really good technicians working with us. Training the technicians in this regard was very important also. They had to understand, how emotionally traumatic it can be because they're the ones that are there in the room with the parents. We especially emphasize the fact that we have to give parents the time that they need, and to be aware that they may need privacy. If a parent seems to be completely overwhelmed, the technician may need to leave the room. I might need to turn the camera off and just give the parents a few minutes to be on their own. In addition, when I first meet the parent I start a relationship with them before I start doing any testing. So I talk with them about what to expect with the program. We also have very large screens so the parent can see me through the entire visit. We knew that if we used small screens and they only had a tiny view of me, it would be more difficult for the parent to relate to me as a real person as compared to having a larger view. I think that has helped.
SMAKA: What are the options for follow up?
SIMON: Part of the goal of our program is to determine which infants who failed the screenings have normal hearing so they can be exited from the program. For those with hearing loss, once a diagnosis has been made and the family knows there is an issue, they are more likely to work out what is needed, even if it involves driving to a facility that is further away.
Depending on the needs of the child, CCS will locate facilities throughout Northern California for each child to follow up. For instance, there are some institutions here that do a lot of cochlear implants, and others that do more BAHA or hearing aids. And there are some places that see infants while others are more comfortable with ages three and up. The idea is to refer the child to a place where they will receive the best care for their situation. The children will receive Early Start services in their home communities.
SMAKA: What do you anticipate your caseload will be for remote diagnostic testing?
SIMON: We're expecting needing to evaluate as many as 60 children in a year, or slightly less as birth rate in this area is down since we did our estimates.
SMAKA: Anne, this has been great. It is so exciting to hear about the program, and it has far-reaching implications for our profession in terms of meeting the needs of our patients as we move forward, both infants and others.
Before we conclude, can you tell me about your background?
SIMON: I am a pediatric audiologist at UC Davis Medical Center. In addition to the Teleaudiology project I coordinate our outpatient newborn hearing screen program, provide diagnoistic and rehabilitative audiology services for all ages and have participated in our Cleft and Carniofacial Team, The teleaudiology program is especially important to me because in addition to taking care of the infants and allowing the parents to stay within their communities, it also means we are doing a little for the environment. As the program progresses and grows I hope we can have a greater impact with fewer cars on the road as family's receive services remotely.
SMAKA: That's true, very good point. Thanks again for your time and best wishes for continued success of the program.
SIMON: Thanks, Carolyn.
ANNE SIMON: We were approached by an audiologist at California Children's Services (CCS) because the lost to follow up rate for newborns who fail hearing screenings in rural Northern California is very high at about 40 percent. The babies who fail the newborn hearing screening in this area were not returning for follow up. And so CCS was looking for a way to help these families receive diagnostic evaluation.
There is a very large expanse of California that's north of Sacramento and extends north to the border of Oregon. Even people who live in California don't realize just how large a portion of the state this is, and how far it is away from Sacramento and the Bay area.
SMAKA: Why was the lost to follow up rate so high in this area?
SIMON: Infants were being screened and re-screened at their birth hospital, and when they didn't pass their screenings, they were told they would have to drive to Sacramento or to the Bay Area for a diagnostic audiology evaluation because there were no providers close to home. Many parents were simply not going, for various reasons. For families in the most remote areas, this might mean an 8 or 9 hour drive one way.
SMAKA: It's understandable how trying to make that trip with a newborn would be a barrier to follow up.
SIMON: Exactly. With a newborn, you would have to stop every couple of hours to feed them, and you may have a day or two off of work. It would be almost impossible to make it round trip in one day, so you may have to incur the cost and inconvenience of an overnight stay, while possibly trying to make arrangements for care of other children, as well. Logistically, it would be very difficult for most families of a newborn.
SMAKA: And we know how hard it is sometimes to impress upon parents about the critical time period we're working with when it comes to hearing loss in infants. If the infant is otherwise healthy, they may not understand how crucial the timeliness of follow up is.
SIMON: Right. Sometimes, as the months went by and the child got older, the parents would notice that the child would be responding to sound and then they would think an evaluation was not necessary. Or, by the time the child would make it in for an evaluation, the child would be several months old and then you could no longer get them to sleep for the ABR. They would have to be evaluated behaviorally, which we all know has its own challenges, not the least of which is that it often takes several appointments, delaying identification.
At UC-Davis Medical Center here in Sacramento, we do a lot of telemedicine. So we partnered with the State of California to develop a program utilizing telemedicine for these infants. The program is funded by a grant from the Maternal and Child Health Burreau at HRSA through the California Department of Education and Health Care Services.
We developed the program with audiologists at California Children's Services and then we chose a site in Redding, California, which is centrally located and one of the largest communities within the area we were looking to target in Northern California. At Mercy Medical Center in Redding we found two wonderful EKG/EEG technicians to work with us. The infants to be tested go to Mercy Medical Center where one of the techs prepares the child for the diagnostic evaluation. The technician then stays with the child and parent throughout the testing, and I perform the test and run the equipment remotely from UC Davis Medical Center in Sacramento.
SMAKA: Where did you get audiology equipment that can be used for remote testing?
SIMON: Any equipment that is PC-based can be used remotely if you have the right software to set it up as well as a secure Internet connection that will safeguard the patient information. All the testing equipment including ABR, ASSR, immittance, OAE and video otoscopy, is equipment generally used in an audiology clinic. We did end up purchasing equipment for this program because we needed equipment at Mercy Medical Center with the baby.
You can think of our teleaudiology program like this. When you have trouble with your computer, you may contact your IT department who then logs in and takes over your computer. They take control of your computer remotely and you sit there and watch them on your monitor as they fix your problem. That's what I'm doing when I test the infant remotely. The audiological equipment is at Mercy Hospital in Redding with the baby, the technician, and the parent. I run a second computer in Sacramento that controls the computer that's in Redding with all the audiological software.
SMAKA: This is amazing. When did this program start and how many infants have been tested remotely?
SIMON: Our first patient was seen in early December, and we've tested three children so far. Things have gone really well. We have an amazing team that includes a researcher and a great IT team. They were instrumental to setting up the connection and the technology, and solving any issues that have come up along the way.
SMAKA: As an audiologist, how does remote testing compare to traditional in-person testing?
SIMON: Although I have a high quality camera with great zoom capabilities, I can not see as much as I can in person. We move the camera stand and the parent's chair often throughout the session so I can see what I need to. I have found it works best to complete testing on one ear and then switch to the second ear instead of the more traditional manner of moving between the ears throughout the ABR evaluation. Tympanometry is taking more time than it would in person. It takes more time to obtain a good probe fit and the equipment is slower through the remote connection. The evaluations are taking more time in general. This is in part because the equipment is new and in part because I am training the technicians to perform the tasks that I normally do.
With two of the children we were able to complete the testing in two sessions, and with the third child we are going to need a third session. Our goal is to get all the audiological information that is necessary to move forward with intervention, whether that means a hearing aid fitting, early intervention, medical follow-up, etc.
As we were developing the program, we talked to other similar programs around the country, so we knew as well as we could what to expect and what we're finding is that remote testing takes a little more time. I find that if I see an infant in person and there is some degree of hearing loss, I often need two sessions to get everything I need and to start towards intervention. Part of the reason remote testing takes a little longer is because we are a new program and had some minor issues like trouble printing tympanometry results. Part of it is simply due to the nature of remote testing. For example, instead of looking at the infant's ear directly in person, I am instructing the technician at the other end where to move the camera, i.e. "Okay, I have viewed that part of the ear now move around to the other side." I do believe that as we get more experienced with it there will be less of a time difference as compared to in person testing.
SMAKA: Yes, it seems to me that even when you are working with new equipment with the patient in person, or in a new treatment room where your equipment or tools are different, the appointment may take more time.
SIMON: Yes, it is expected and it improves with familiarity.
SMAKA: What have the parents or caregivers reactions been? Have you gotten their feedback?
Infant Jack James rests in his mother Michelle's arms while undergoing audiology testing via a telemedicine arrangement between Mercy Medical Center, Redding and UC Davis. The patient is in Redding, California and the audiologist is in Sacramento, California. Photo credit: UC Regents.
SIMON: Yes, their feedback is important to us. All three sets of parents have been very pleased that they've been offered to participate in the program. They've all been very pleased that they didn't have to travel. Two of them have no prior experience with having a diagnostic evaluation like this so to them, this is normal. They are very happy to know their child is receiving the necessary evaluation that he or she needs.
When the child fails the hearing screening, the parents are given the option of an in-person diagnostic evaluation in the Bay Area or Sacramento, or via this teleaudiology program. I imagine that once they hear they can do this close to home they're interested to know that they have a choice.
In addition to the diagnostic component of this program, there is also a research component, and the families that participate in the diagnostic testing also agree to participate in the research.
SMAKA: What are you looking at in terms of research, the teleaudiology component?
SIMON: We know that ABR can be done remotely;there's been previous research that shows it can be done accurately. Instead, we're looking at patient satisfaction. We are also interested in the audiologist's perspective - does the audiologist feel that we're providing a sufficiently appropriate evaluation for the child? We are looking at the evaluation in its entirety - ABR, ASSR, and all the other diagnostic testing. We are looking at factors such as timeliness, determining if we are meeting our goal of identification by 3 months of age, and looking at outcomes.
SMAKA: You mentioned that in designing this program you connected with other teleaudiology programs?
SIMON: Yes, The audiologists at California Children's Services connected with the other programs to share information in order to help design a program that would be most successful. Four other facilities received the same grant that we did, and so, an audiologist with CCS, was communicating with them every few months to find out how they were doing, what their challenges were and sharing our experiences.
And then also, our technology team was communicating with people on the technology side of the other programs to make sure we were on the same page in terms of our connections. Everyone that is involved in teleaudiology now - whether it's here at UCD, in another State, or internationally - is a trailblazer. Teleaudiology is new for everyone, so it's wonderful when people can talk with each other, share information and learn from one another.
SMAKA: We know that counseling is extremely important as you need to help parents with their journey and also facilitate moving them to the next steps. How has counseling remotely been for you as an audiologist as opposed to counseling in person?
SIMON: It was one of my primary concerns going into this. All pediatric audiologists have had to tell parents that their child has hearing loss and we know how difficult that can be for the parent. Now envision telling a parent that their child has hearing loss when you're not in the room with them.
We did a few things to help make this work. First of all, we have really good technicians working with us. Training the technicians in this regard was very important also. They had to understand, how emotionally traumatic it can be because they're the ones that are there in the room with the parents. We especially emphasize the fact that we have to give parents the time that they need, and to be aware that they may need privacy. If a parent seems to be completely overwhelmed, the technician may need to leave the room. I might need to turn the camera off and just give the parents a few minutes to be on their own. In addition, when I first meet the parent I start a relationship with them before I start doing any testing. So I talk with them about what to expect with the program. We also have very large screens so the parent can see me through the entire visit. We knew that if we used small screens and they only had a tiny view of me, it would be more difficult for the parent to relate to me as a real person as compared to having a larger view. I think that has helped.
SMAKA: What are the options for follow up?
SIMON: Part of the goal of our program is to determine which infants who failed the screenings have normal hearing so they can be exited from the program. For those with hearing loss, once a diagnosis has been made and the family knows there is an issue, they are more likely to work out what is needed, even if it involves driving to a facility that is further away.
Depending on the needs of the child, CCS will locate facilities throughout Northern California for each child to follow up. For instance, there are some institutions here that do a lot of cochlear implants, and others that do more BAHA or hearing aids. And there are some places that see infants while others are more comfortable with ages three and up. The idea is to refer the child to a place where they will receive the best care for their situation. The children will receive Early Start services in their home communities.
SMAKA: What do you anticipate your caseload will be for remote diagnostic testing?
SIMON: We're expecting needing to evaluate as many as 60 children in a year, or slightly less as birth rate in this area is down since we did our estimates.
SMAKA: Anne, this has been great. It is so exciting to hear about the program, and it has far-reaching implications for our profession in terms of meeting the needs of our patients as we move forward, both infants and others.
Before we conclude, can you tell me about your background?
SIMON: I am a pediatric audiologist at UC Davis Medical Center. In addition to the Teleaudiology project I coordinate our outpatient newborn hearing screen program, provide diagnoistic and rehabilitative audiology services for all ages and have participated in our Cleft and Carniofacial Team, The teleaudiology program is especially important to me because in addition to taking care of the infants and allowing the parents to stay within their communities, it also means we are doing a little for the environment. As the program progresses and grows I hope we can have a greater impact with fewer cars on the road as family's receive services remotely.
SMAKA: That's true, very good point. Thanks again for your time and best wishes for continued success of the program.
SIMON: Thanks, Carolyn.
