Current Practices in Tele-audiology
Veterans Administration (VA)—Potential Telehealth Applications in Audiology
(Presentation by Chad Gladden, AuD, 2013, The Current Status of VA Audiology)
- Remote troubleshooting/programming of hearing aids and cochlear implants
- Home-based aftercare
- Remote assessment of hearing
- Facilitated home-based auditory rehabilitation
- Remote assessment of balance disorders
- Store–and-forward applications: master clinicians, imaging, test interpretation
Statistics: Approximately 60 percent of enrolled veterans reside in urban areas, while approximately 37 percent reside in rural areas and fewer than two percent reside in highly rural areas. Travel distance and geographic barriers limit access to specialized clinical services. A shortage of trained health-care professionals and specialized facilities in rural areas means that many health services are unavailable to the majority of the rural population.
The Beginning: VA pilot programs began in 2009.
- Joint effort with Telehealth Services, Office of Rehabilitation Services, and the Audiology and Speech Pathology National Program Office.
- Used community-based outpatient clinics (CBOCs); performed hearing aid tele-programming using remote control software with hearing aid fitting software at 10 pilot sites (rural locations).
- All sites provided with telehealth equipment, specialized audiology equipment, technician staff, and software.
- Pilot sites evaluated for feasibility of remote programming, and moved the project from proof of concept to a viable clinical tool for national implementation.
- The VA collected 1,170 telehealth outcomes. Telehealth outcomes are as good as or better than traditional face-to-face encounters.
- From 2009 to 2013, there has been a large increase in audiology telehealth at the VA.
Next Phases for the VA: Phase II Remote Audiometry, Phase III Evaluate Home-based Tele-audiology and Phase IV Home-based Tele-rehabilitation
VA Health-care System
- Video otoscopy, hearing aid fittings, verification, troubleshooting, counseling, and aural rehabilitation.
- Fitting/Programming is performed by an audiologist; HA connection/set-up by a technician at the CBOC.
- Currently working with clinics in Key Largo, Key West, and Homestead.
Pediatric Pilot Study
- Children’s Hospital Colorado developed a pilot project with the Early Hearing Detection and Intervention (EHDI) program in Guam.
- Guam EHDI purchased PC-based diagnostic audiology equipment needed for infant OAEs. Children’s Colorado audiologists control this equipment from their desktop computers in Colorado using remote control software.
- Eight infants have been tested by tele-audiology. No technical or environmental issues have interfered with tele-audiology or prevented satisfactory completion of the test battery for these infants. Minor technical problems, such as dropped Internet connectivity and videoconferencing failures, were resolved promptly on the few occasions they occurred.
- Pilot project demonstrates that tele-audiology for infant OAEs can be accomplished using hardware and software applications readily available on the commercial market. For infants and their families in Guam, tele-audiology makes the EHDI goal of diagnosis by age three months feasible.
- Ear scanning technology (3D image) captures the ear canal and the concha. The image is transmitted to the appropriate instrument manufacturer.
- Time is less than two minutes.
- Shipping cost is eliminated.
- Test can be performed via telehealth with a technician.
- This is commercially available in 2014.
Cochlear Implants (Wasowski et al., 2012)
- Study consisted of 94 cochlear implant users scheduled for tele-fitting in one of eight centers selected for this study. 195 patients were surveyed.
- Each patient underwent a tele-consultation procedure. The patient was then presented with a questionnaire relating to the quality and time effectiveness of tele-fitting and the preparation process, assessment of the ease of contact with the audiologist, the sense of security and calm during the session, and an overall assessment of its usefulness.
- The Nationwide Network of Tele-audiology proved to be a reliable platform for tele-fitting. The method and proposed model of postoperative care for implanted patients using telemedicine seems to be a reliable alternative to the/a standard model. It improves the quality of service provided to patients and saves substantial time and money.
Tele-audiology Applications (currently being put in place)
- Pediatric evaluations with pure tone, tympanometry, and otoacoustic emissions (Case Western Reserve University, Cleveland, OH).
- “Store-and-Forward” ENT medical clearance (Norton Sound Health Corporation, AK).
- Mentoring and post-doctoral training with telehealth supervision (Marion Downs Hearing Center, CO).
- Development of protocols for infant diagnostics (HRSA Grant awarded to Minot State University, ND).
- Infant diagnostics for ruling out hearing loss (Thunder Bay, Ont).
- Cochlear implant mapping (St. Petersburg and Sarasota, FL).
- Tele-intervention and parent coaching (Utah State University, UT).
- Connecting third world countries to audiology services in developed nations (University of Pretoria, SA).
- Hearing aid fittings (Mayo Clinic, MN).
- Audiometric evaluations (Minot State University, ND).
- Live videoconferences with patients (Mark Krumm, AAA Taskforce on telehealth and tele-audiology).
- Telemedicine initiative in Vanderbilt University’s Department of Hearing and Speech Sciences is working to make follow-up hearing tests for newborns more accessible in rural areas of Tennessee.
- University of California Davis is launching a pediatric audiology telemedicine program in northern California: The tele-audiology program uses telemedicine to provide comprehensive audiology diagnostic evaluations over long distances. This program evaluates infants who do not pass their newborn hearing screen.
- Tinnitus treatment (Tinnitus Treatment Solutions).
- Royal Institute for Deaf and Blind Children (RIDBC) (NSW AU) has a research project that aims to allow city-based audiologists to test children’s hearing remotely, relying only on unqualified helpers at the remote site.
- Cochlear implants: (Queensland’s Hear and Say in conjunction with Sydney Cochlear Implant Centre NSW AU).
Issues to Consider
- Are data accurate? False negatives could be a problem. This is especially true with Internet self test/self screening where there is a lack of control over environmental variables like noise level and transducer type.
- Health literacy: Do users understand the results? Studies have shown a link between low literacy and poor health outcomes. Complex messages need to be conveyed to individuals who may have limited literacy skills or understanding.
- Do self-conducted tests motivate behavior change?
- Are families going to like telemedicine services?
- What is the efficacy of using interpreters via telemedicine?
- Is the quality of the diagnostic evaluation going to be effected?
- Will offering services closer to home impact no-show rates?
- What are the costs of technology?
- How will professional standards be maintained?
- What is the expected reimbursement?
- How will licensure laws impact practice?
- How will confidentiality be maintained?
- What are the malpractice risks?
- Is there a preference for face-to-face interaction?
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