Health-care providers are scrambling to keep up with the demand for telehealth services as the coronavirus (COVID-19) pandemic sweeps across the nation and world. Many are seeing unexpected benefits in the shift to connected health—and hoping the momentum continues after the emergency is over. 

Similarly, audiologists are also looking for ways to reach their patients for regular check-ups, follow-up care, and other unexpected urgencies that need attention. The answer to current social distancing can be addressed by adopting tele-audiology. The concept of tele-audiology is not new. It has been applied by many agencies and practices in developing countries to help the unserved and underserved populations and to overcome the shortage of audiologists. 

The scope of this article is to examine the opportunity tele-audiology can provide to clinical challenges associated with social distancing. I have invited content experts in different areas of audiology to share how tele-audiology services are laying the groundwork for “the new normal.” We will review the following:

  1. Identification and diagnostic assessment of hearing disorders.
  2. Intervention for hearing loss and related disorders, including hearing aid dispensing and post-fitting care, cochlear implant post-fitting care, auditory training, and tinnitus management. 

The tele-audiology delivery model can be grouped into two categories. The first model is applied with a satellite clinic or a physical location away from the main clinic. The second model exclusively relies on mobile technology outside of the clinic. 

The first model of care, in addition to physical location, requires equipment similar to that in the main clinic and a qualified assistant or facilitator. The second model is exclusively based on mobile technology like smartphones, tablets, notebook, and computers. In this model, the virtual space becomes the satellite clinic. The requirements, similarities and differences between the two models are listed in TABLE 1.  

TABLE 1. Comparison of Two Models of Tele-audiology and the Requirements for Implementation

REQUIREMENTS 

MODEL 1

MODEL 2

STRATEGIC PLANNING

Yes.

Yes.

NEEDS ASSESSMENT

Market analysis and a clear and business plan are important.

Market analysis and a business plan are important. 

SPACE REQUIREMENTS

Satellite clinic.

Virtual clinic.

EQUIPMENT

The types of test equipment depend on the mission of the satellite clinic. 

Basic components include:

Internet connection, video otoscope audiometer, middle ear measurement device, equipment for real-ear measures, 3D-ear scanner for taking impression of the ear, other equipment as needed.

Mobile smartphone, tablet, computer, internet connection, calibrated headphones.

IDENTIFICATION/DIAGNOSIS 

A fully functional satellite clinic is capable of performing all tests.

Currently technology permits hearing screening, hearing threshold assessment, and speech audiometry.

TRAINING STAFF AT MAIN CLINIC AND SATELLITE CLINIC

Critical to train the staff at both locations.

No facilitators are needed for this model, but a thorough understanding of technology is required.

VIDEO VISITS BETWEEN AUDIOLOGISTS AND PATIENTS

Video visits can be achieved by using communication platform that is HIPAA-compliant; currently, HIPAA compliance has been relaxed.

Video visits can be achieved by using communication platform that is HIPAA-compliant; currently, HIPAA compliance has been relaxed.

PAYMENT 

Several private payers pay for such services, not for Medicare patients.

This is a new service, and the reimbursement should be negotiated or private pay options explored.

HEARING AIDS AND COCHLEAR IMPLANTS

These services can be provided using tele-audiology. 

These services can be provided using tele-audiology. 

AUDITORY TRAINING AND TINNITUS 

These services can be provided using tele-audiology. Video visits can be used as well as hybrid models that include asynchronous models between video sessions.

There are multiple smartphone, tablet, computer, and web-based tools for tinnitus and auditory training that can be used. Video visits can also be used. 

 

Hearing Loss Identification

Online or self-hearing testing has grown in recent years to serve the growing direct-to-consumer (DTC) hearing-device market. For the purposes of this discussion, online (PC- or smartphone app-administered) hearing testing is distinguished from remote administration of conventional manual or automated audiometry overseen by a technician at a satellite clinic. Also not included here are at-home hearing tests that require the use of application software and calibrated headphones. 

Online hearing testing is primarily designed to identify the possible presence of a hearing impairment for the purposes of advising the user to seek additional professional care, to provide a manufacturer with information concerning a potential hearing aid user, or to initially program a device as part of a DTC process. These tests incorporate tones, words, numbers and/or everyday sounds in quiet or in noise as target stimuli. 

Research is underway to determine the use and effectiveness of online or self-hearing testing. Not surprisingly, the accuracy of online hearing tests, when compared to conventional audiometry, varies as a function of transducer type and degree of hearing loss. 

Barczik and Serpanos (2018) found that online hearing tests were generally accurate for threshold assessment of mild or greater (>25 dB HL) hearing loss when using appropriate transducers. Likewise, Saliba et al (2017) demonstrated that mobile-administered audiometry was within 10 dB of conventional audiometry when conducted in a quiet environment. This is an emerging technology, and we should expect to see considerable growth in online testing with the issuance of Food and Drug Administration (FDA) regulations concerning over-the-counter hearing aids.

Hearing Loss Assessment

The recent surge in clinical investigation of tele-audiology is motivated largely by the need to make quality hearing-health-care services accessible to underserved populations, particularly in developing regions of the world lacking adequate audiology services. 

Using Model 1 discussed earlier, it is possible for an audiologist to complete each step of a typical hearing assessment process, including a focused history to rule out ear disease (e.g., CEDRA), remote otoscopic inspection of the ear, hearing screening , pure-tone threshold assessment, and speech audiometry in quiet and noise (Klyn et al, 2019; De Sousa et al, 2019; Swanepoel 2020). 

Due to COVID-19, social-distancing and self-quarantine policies and protocols seriously restrict the assistance of technicians, facilitators, or other non-audiology personnel in providing remote patient services (Model 1). Fortunately, several rather straightforward approaches, supported by novel technologies, are available for delivery of quality hearing-health-care services while minimizing the risk of patient infection. 

With some creativity, audiologists can conduct or coordinate each step of the hearing assessment process without any direct patient contact, that is, with patients collecting their own audiological data either independently with self-test systems or with the assistance of a family member (Model 2). 

Interventions

Interventions for hearing loss and related disorders include hearing aid dispensing and post-fitting care, cochlear implant post-fitting care, auditory training, and tinnitus management. 

Hearing Aids

As consumers with hearing loss seek convenient solutions to address their hearing health-care needs, audiologists must look for innovative and creative solutions for meeting the needs of the consumer in the comfort of their home, or potentially at a local clinic down the block. 

Technology today has opened opportunities for audiologists to explore many iterations of fitting and follow-up options depending on the needs of the consumer. Mobile and internet technology can be used to present self-assessment questionnaires, such as the Hearing Handicap Inventory for the Elderly/Adults (HHIA/E), International Outcome Inventory for Hearing Aids (IOI-HA), Satisfaction with Amplification in Daily Living (SADL), and Client-Oriented Scale of Improvement (COSI). 

Remote real-ear measures can be done reliably with the assistance of a technician, and in-situ audiometry, through the manufacturer software, if all else fails. Hearing aid adjustments can be implemented using remote access of a PC, real-time remote programming, or asynchronous programming. 

The hearing aid industry has contributed many advancements to Bluetooth technology for connectivity, as well as created opportunities for audiologists to meet patient needs outside the clinic. TABLE 2 provides a summary of some of the features and functions audiologists can use depending on manufacturer availability. 

TABLE 2. Summary of Features Available via Smartphone Apps and Remote Programming*

FEATURE

DESCRIPTION

FINE TUNING 

Full and limited fine-tuning via real-time and asynchronous remote programming

FITTING

Feedback measurements 

In-situ audiometry

SATISFACTION SURVEYS 

Ability to rate listening situations and programming adjustments

TRACKING 

Ability to see battery charge and datalogging

REMOTE FIRMWARE AND SOFTWARE UPGRADES

Ability to update device firmware remotely 

HARDWARE DIAGNOSTICS

Ability to identify mic, speaker, and internal noise issues 

CONSUMER REMOTE CONTROL

Tone control 

Volume control 

Compression control

Directional control

Noise reduction

Tinnitus control

Speech enhancement

Creation of custom programs 

*Audiologists should check with manufacturer to see if specific feature available.

 

Tele-audiology in hearing aid follow-up and care are can also be conducted via offline platforms (e.g., DVD, telephone), using the internet (e.g., websites, remote access, videoconference, messaging system/email) and via mobile solutions (e.g., smartphone/tablet) (Paglialonga, 2018). 

Cochlear Implants 

In a situation where the clinics are in lock-down, the satellite clinic model is often not helpful as travel and physical interaction are still required. Therefore, during this time, it is imperative to think outside the box and focus on the patient’s specific need rather than the traditional care pathway. 

This is especially true for cochlear implant users who live greater distances from their providers. A simple questionnaire can help the clinic understand the patient need, and video calls are available if specific follow up is needed. A well-designed triage tool can help determine if the patient needs to see their doctor, get a new part or repair from the device manufacturer, or need counselling. 

Cochlear recently received FDA approval for its Remote Check solution, which is a smartphone app that provides a convenient and valuable way for clinics and their patients to connect and share relevant information (Slager er al, 2017). The information includes implant site photos, various triage questions, and two direct connect streamed hearing tests. The tool provides information for a clinician to make an informed decision on whether an in-clinic visit is needed, no visit is required, or other intervention is needed. 

If the need is device training or repair, the patient can often contact the device manufacturer through their consumer hotlines. For example, Cochlear Link enables the sharing of the clinic database with Cochlear so the company can quickly and securely access the patients’ latest program (MAP) via the “cloud” and expedite service and repair requests for the patient as quickly as the next business day without any clinic involvement. 

If changes to the patient’s program are required, patients can make limited changes to their MAPS using their smartphone, often with the support of the audiologist.1 If further changes are required, then at-home remote programming is possible.2 While the at-home remote programming can be logistically challenging, one study showed it provides equivalent results (Slager, et al, 2017).

Auditory Training 

As the audiology community transitions many of their clinical services to a telehealth platform, it’s important to remember that many services are particularly well-suited to deliver remotely and have been so for quite some time. 

One example is computer-based auditory training (CBAT). Commercially available CBAT programs include, for example, Listening and Communication Enhancement (LACE) and clEAR EARS for the Brain. Some manufacturers have developed auditory training apps such as Hear Coach by Starkey and rehAB by Advanced Bionics. While not specifically marketed as auditory training programs, “Brain Fitness” programs such as Lumosity and BrainHQ are designed to improve auditory processing functions that tend to be compromised as a result of age-related hearing loss, such as working memory, speed of processing, and selective attention. 

What these programs have in common is that they employ the principle of gamification—the application of gaming strategies for non-gaming purposes such as health and wellness. These strategies include adapting the difficulty of the task, awarding points, and achieving higher levels based on the participant’s performance to keep them engaged and coming back for more training. 

Research has demonstrated mixed results concerning the efficacy of CBAT programs (e.g., Abrams, 2015; Saunders et al, 2016). Although auditory training programs can be completed remotely, it’s important for the audiologist to remain engaged with and monitor the progress of their patients to ensure their continued compliance, a challenge for even the most entertaining applications.

Tinnitus

Tinnitus is a heterogeneous condition by its etiology and presentation. Assessment should focus on (1) identifying red flags in terms of serious auditory pathologies and/or psychological conditions leading to additional and detailed audiological and/or psychological evaluations and (2) evaluation of the effects of tinnitus on day-to-day life and work. 

Tinnitus-management options are based on the resulting severity and associated comorbidities such as anxiety, depression, or insomnia. Audiologists can offer tinnitus management using tele-audiology methods. This can be done by obtaining a detailed case-history and self-reported outcome measures such as the Tinnitus Functional Index (TFI) or Tinnitus Handicap Inventory (THI) and other validated scales for comorbid conditions. In addition, survey tools such as SurveyMonkey or Qualtrics will aid in the diagnosis of tinnitus. 

Most tinnitus suffers find tinnitus bothersome and may have some associated mild anxiety. For such individuals, informational counseling aimed at reassurance and increased understanding may be enough and can be offered online using encrypted technologies such as Skype. However, some individuals with severe tinnitus destress and other comorbidities, such as sleeping problems, high anxiety and depression, may require a structured program. 

Various psychological approaches including Cognitive Behavioral Therapy (CBT) and Progressive Tinnitus Management (PTM) have been found to be effective and all of them can be done via tele-audiology methods (Beukes et al, 2018; Henry et al, 2018). 

A few prominent psychologists have been offering successful tinnitus management such as CBT and Mindfulness-based Tinnitus Stress Reduction using video coaching methods. Finally, the structured psychological therapies of choice (e.g., CBT, PTM) can be offered via the internet and smartphone apps (Sereda et al, 2019). This can involve regular meetings using video coaching techniques. In addition, web pages with self-help information and smartphone apps can be used with patients to supplement the video coaching sessions. 

Conclusion 

This article reviewed the current state of tele-audiology using either Model 1 or Model 2. In conclusion, the availability of present mobile technology can support most clinical services offered using tele-audiology. However, the use of a complete mobile platform without the assistance of a remote site with an assistant or facilitator addressed in Model 1 is still evolving. We foresee an opportunity for these emerging care models to lead to improved and more efficient hearing health care for consumers in the long term.