Geographical distance and provider shortage in the state of Alaska make access to specialist health care, such as audiology, difficult. To address this challenge, Alaska has developed a homegrown telehealth network that connects small rural community clinics to specialists. Pre- and post-operative care, management of otologic disease and hearing loss, hearing aid programming, and newborn hearing screening follow-up are a few examples of telehealth-based services provided by audiologists in remote Alaska.
Role of Telehealth
Seventy-seven million people in the United States live in designated health professional shortage areas, with 62 percent in rural areas and 31 percent in non-rural areas (Health Resources and Services Administration, 2019). Shortages in health-care professionals prevent access to timely care. Access limits are further exacerbated by a lack of basic insurance coverage (Institute of Medicine, 2009).
Telehealth, or the use of medical information exchanged from one site to another through electronic communications to improve a patient’s health (American Telemedicine Association), is a powerful tool for delivering cost-effective access to state-of-the-art medical expertise. Telehealth is not a separate specialty but rather a method for delivering health care, and if implemented well, can be the great equalizer in access to medical care across the population.
Infrastructure in Rural Alaska
Alaska is a state that mirrors the geographic and provider shortage challenges for the provision of health care in rural America. Approximately 75 percent of Alaskan communities are not connected to the road system, necessitating travel by plane to be seen by a specialist (Goldsmith, et al, 2004). The majority of Alaska is medically underserved, with approximately 370,000 (59 percent) residents geographically spread in remote locations across the state (Alaska Department of Health and Human Resources, 2010).
Population sparsity (1.2 per square mile) and a low ratio of doctors to residents further exacerbate delays in health-care delivery in Alaska. Because the majority of Alaska-based physicians are concentrated in more urban areas, the ratio of doctors to residents is worse in rural areas, with at least a 16 percent vacancy in physician positions outside of Anchorage, Alaska’s largest city (Alaska Physician Supply Task Force, 2006).
To address these challenges, Alaska built a robust telehealth-networked solution to improve access to care. One of the largest telehealth endeavors in the world is the Alaska Federal Healthcare Access Network (AFHCAN), the primary telehealth solution in Alaska since its implementation in 2001. AFHCAN is the result of a $30 million grant-funded project established in 1998, which started as an initiative by the Alaska Federal Healthcare Partnership and involved the collaboration of multiple organizations.
Since its implementation, this statewide telehealth network has been integrated into clinical practice in more than 250 clinics across the state. AFHCAN offers multiple medical devices for the collection of health-care data, such as video otoscope, audiometer/tympanometer, dental camera, electrocardiogram, spirometer, vital signs monitor, scanner, and digital camera (FIGURE 1). This allows consultations to be created at the community level by local providers, such as community health aides (CHAs) (Golnick et al, 2012) and read remotely by specialists, such as audiologists, cardiologists, dentists, dermatologists, and otolaryngologists (Carroll et al, 2011; Hays et al, 2014; Kokesh et al, 2004, 2011; Patricoski, 2004).
Through telehealth, a specialist can manage care provided by CHAs in a village or expedite travel to a regional or state hospital if an in-person visit, imaging, or surgery is required, thus bypassing delays in receiving necessary health care.
Applications in Audiology
Provision of audiology services in rural Alaska requires creative solutions to meet patient needs due to the large geographic distance between the provider and the population. Nearly all audiological care is triaged through a telehealth workflow to increase access and timeliness of care and reduce unnecessary travel (FIGURE 2).
In some rural programs, nearly half of audiology encounters are provided through telehealth. A combination of store-and-forward and real-time video teleconference (VTC) telehealth solutions are used to meet the otological and audiological needs of the population.
The rate of hearing loss due to otitis media is higher in the rural Alaska Native population compared to the general U.S. population (Barnes et al, 2010; Reed and Dunn, 1970; Singleton et al, 2009). This necessitates a large proportion of audiological care encompassing telehealth exchange with otolaryngologists (ENTs) located in Anchorage. The majority of otological disease management and surgical decision-making is done using store-and-forward telehealth, which is well validated (Kokesh et al, 2004, 2011; Patricoski, 2004).
CASE STUDY #1. | Bilateral Cholesteatoma
- 29-year-old male presented to audiology
- during a remote field clinic for draining ear
- Found to have large perforations with suspected cholesteatomas and maximum conductive hearing loss bilaterally
- Images, tympanometry, audiometric thresholds sent to ENT through store-and-forward telehealth
- Same-day response with significant concern and recommendations for timely surgical care
- Due to patient tentativeness to travel, VTC telehealth with ENT was scheduled to address patient concerns in real time
- Patient received surgical intervention at state hospital in Anchorage within weeks of initial telehealth referral
CASE STUDY #2 | Nasopharyngeal Carcinoma
- 26-year-old male presented to audiology during a remote field clinic for decreased hearing and left-sided tinnitus
- Otologic hx included: Bilateral myringotomy and tubes (MT) as child and right tympanoplasty
- On exam, left serous effusion with immobile tympanogram and 30-40 dB drop in air conduction compared to baseline audiogram
- ENT consulted through store-and-forward telehealth and recommended for nasopharyneal exam
- Seen one month later in an ENT field clinic at regional hospital and concern for mass noted on exam
- Flown to state hospital in Anchorage for imaging, biopsy, and left MT
- Patient received surgical intervention at state hospital in Anchorage within weeks of initial telehealth referral
- Found to have a malignant tumor and presented to Tumor Board with initial presenting symptom of serous effusion
- Currently managed jointly by oncology and ENT for nasopharyngeal carcinoma
CASE STUDY #3 | Sudden Hearing Loss
- 45-year-old male presented to audiology with sudden change to left ear hearing following a cold
- Found to have a moderate to profound asymmetrical sensorineural hearing loss left and ~ 50 dB drop in hearing
- ENT consulted through store-and-forward telehealth with immediate treatment of Prednisone taper
- Repeat diagnostic hearing test at one-week follow-up indicated complete restoration of hearing
CASE STUDY #4 | Unilateral Sensorineural Hearing Loss
- Newborn born at 36 weeks, no complications with pregnancy/birth
- No family history of hearing loss but older siblings with history of recurrent ear infections and tubes
- Referred newborn hearing screening on automated auditory brainstem response (AABR) left ear, passed right ear
- Five weeks—completed VTC telehealth with audiology (otoscopy, tympanometry, distortion product optoacoustic emissions [DPOAEs], counseling) with overall results showing referred DPOAE screening (4 freq) left, passed right
- Seven weeks—completed AABR at regional hospital, which referred left with concern for otitis media; treated with course of amoxicillin per store-and-forward telehealth with ENT
- Eight weeks—completed diagnostic ABR at regional hospital, no sign of acute infection; ABR normal Wave V on click @ 20 dB nHL for right ear and no response left @ 90 dB nHL for the left ear; store-and-forward telehealth with ENT resulted in coordinated scheduling of binocular microscope exam, genetics, and ophthalmology
- Currently fit with amplification, and in discussion for cochlear implant
CASE STUDY #5 | Remote Amplification Fitting
- 69-year-old male with mild sloping to profound sensorineural hearing loss bilaterally
- Seen in person by audiology in field clinic for diagnostic hearing testing, real-ear-to-coupler device (RECD) measures, and custom impressions
- Technology with extra supplies, accessories, tools sent to island via helicopter
- Worked with CHA using VTC telehealth to size and fit earmolds, tubing, placement of hearing devices, communication to patient, counseling, orientation, and validation measures (client-oriented scale of improvement, COSI) and Remote Desktop Connection for programming and first fit testing
- Completed all follow-up appointments using VTC and Remote Desktop Connection
Cases #1 and #2: Bilateral Cholesteatoma and Nasopharyngeal Carcinoma
Case studies #1 and #2 are examples of patients identified with ear disease who received high-level specialist care within hours of presenting to the clinic and went on to receive timely surgical and medical intervention.
Case Study #3: Sudden Hearing Loss
Audiology in rural Alaska uses store-and-forward telehealth for diagnostic audiology indicating medical management. The use of telehealth results in immediate treatment for conditions such as labyrinthitis or idiopathic sudden neurosensory hearing loss, which requires immediate medical care and timely treatment of steroids or scheduling of a magnetic resonance imaging (MRI) of the internal auditory canals to rule out the presence of neuroma.
Case study #3 is one example of a patient who received rapid diagnosis and treatment through provider-to-provider, store-and-forward telehealth.
Case Study #4: Unilateral Sensorineural Hearing Loss
In rural Alaska, completing follow-up for referred or missed newborn hearing screenings is a challenge. One reason for this loss to follow-up is a family’s reluctance to travel for medical appointments.
To address this challenge and increase the percentage of children diagnosed before three months of age, the state partnered with rural audiology programs to implement the integration of audiology equipment into the existing AFHCAN system.
The increased availability of audiometric data in clinics through telehealth has brought follow-up rates to nearly 100 percent, with families keeping appointments because of the reduced travel burden.
Take case study #4, for example, where a mom was willing to complete a newborn hearing screening follow-up appointment if it did not require travel. This was due to the importance of subsistence to the way of life in rural Alaska. It was opening season for moose-hunting—an essential time for her family to be out hunting. The ability to do a telehealth appointment in her home community enabled timely hearing screening and follow-up for this newborn.
Case Study #5 Remote Amplification Fitting
Rehabilitation for remote audiology services also depends on the use of telehealth solutions to give patients the necessary ongoing care. To meet this need, rural audiology programs have piloted programming over distance that uses remote-desktop and real-time VTC technologies to provide follow-up after amplification fittings.
This follow-up care can include everything from additional programming adjustments and counseling to guiding CHAs through earmold fittings. In the most isolated of environments, the use of telehealth for amplification is extended to remote technology and fittings.
Case study #5 is an example of a 69-year-old male located on an island only accessible weekly by helicopter when weather permits. Often travel to or from the island can mean weeks away from home. To provide audiological care to this elder without requiring him to leave the island, a combination of store-and-forward and real-time VTC telehealth solutions were used.
While the use of telehealth solutions have been well used for clinical care, they recently are being used as a preventive tool following referred school hearing screenings. Using telehealth as a preventive tool to connect children to specialist triage is an innovative solution to address the long-standing problem of loss to follow-up after school hearing screening.
Mobile health (mHealth) screening and telemedicine referral to improve the effectiveness of the school-based hearing screenings and the referral process in remote communities served by Norton Sound Health Corporation is being evaluated in a randomized trial involving 1,481 children in northwestern Alaska (Emmett et al, 2019; Emmett et al, 2019b). This ongoing trial has implications for the use of telehealth for prevention across Alaska and in other remote communities worldwide.
There are many state-specific resources for professionals and organizations looking to incorporate telehealth solutions in their facilities (for example, www.telehealthresourcecenter.org). The formation of telehealth solutions must be based on a clear assessment of needs, the type of model for the existing environment, and the sustainability of the program, including reimbursement and market potential.
Implemented solutions should receive ongoing assessments, including service usage, quality of service and outcomes, as well as analyses of financial performance (Weinstein et al, 2008).
Key elements to the development and planning of any program include the following:
1. Use of appropriate equipment and
2. Well-trained, highly experienced personnel.
The most appropriate equipment in many cases, is mobile, or mHealth, technology that has universal access and a user-friendly interface. Furthermore, the technology must be able to integrate with the electronic health record.
It is essential that telehealth models be built upon continuity of care and connected care that allow for the management of complex and chronic problems. Lastly, the importance of the right care team and providers for the provision of services through telehealth cannot be underestimated. From thorough training to specialist expertise, the success of telehealth solutions comes down to the professionals that use them and the foundation of those relationships, whether it be provider-to-provider or patient-to-provider.
The use of telehealth solutions in health care has the potential to increase access to care for underserved populations. Despite broad adoption, existing barriers include state-specific boundaries, such as licensure and insurance laws and regulations. Furthermore, while coverage by Medicaid and Medicare has historically been limited, there is growing recognition by the federal government of the role of telehealth in increasing access to health care.
Opportunities for telehealth solutions are also expanding as new technologies emerge and consumers drive the market. Smartphone peripherals, such as otoscopes, hearing testing, electrocardiogram, stethoscopes, ultrasound, and remote-patient monitoring are helping to enable less visit-centric health care, better continuity of care, and increased communication with patients.