Telehealth, Telehealth, Telemedicine, Telerehab Telemedicine, Telerehab

Where does Audiology Stand and Where does Audiology Stand and Where are We Headed?Where are We Headed?

Catherine PalmerCatherine Palmer

University of PittsburghUniversity of Pittsburgh

Gaining Perspective…100 years agoGaining Perspective…100 years ago

Average life expectancy was 47 yearsAverage life expectancy was 47 years 14% of homes had a bathtub14% of homes had a bathtub 8% of homes had a telephone8% of homes had a telephone There were 8000 cars and 144 miles of There were 8000 cars and 144 miles of

paved roadspaved roads Maximum speed limit in most cities was 10 Maximum speed limit in most cities was 10

mphmph 95% of births took place at home95% of births took place at home 95% of doctors had no college education95% of doctors had no college education 6% of Americans graduated from High 6% of Americans graduated from High

SchoolSchool 2 of 10 adults couldn’t read or write2 of 10 adults couldn’t read or write

Tele…Tele…

Far or DistantFar or Distant Care at a distance Care at a distance

• In absentia careIn absentia care

Raise your hand if you have Raise your hand if you have participated in Telehealth as participated in Telehealth as

a provider.a provider.

Agency for Healthcare Research Agency for Healthcare Research and Qualityand Quality

Telemedicine is the use of Telemedicine is the use of telecommunications technology for telecommunications technology for medical diagnostic, monitoring, and medical diagnostic, monitoring, and therapeutic purposes when distance therapeutic purposes when distance separates the users.separates the users.

Telehealth Act (1996)Telehealth Act (1996)

……encouraged a greater variety of encouraged a greater variety of services by all health professionalsservices by all health professionals

Telehealth is the provision of health Telehealth is the provision of health services from one location to another services from one location to another using a computer network, the using a computer network, the internet, telephone, or other internet, telephone, or other telecommunication mediumstelecommunication mediums

DefinitionsDefinitions

The term telepractice has been The term telepractice has been adopted to encompass both the adopted to encompass both the delivery of clinical services and the delivery of clinical services and the provision of health-related provision of health-related information…information…

Popular DefinitionsPopular Definitions

Right care at the right time in the Right care at the right time in the right place (VA)right place (VA)

There’s been a realization that the There’s been a realization that the exam room is wherever the patient exam room is wherever the patient is…(Jay Sanders, MD)is…(Jay Sanders, MD)

E-HealthE-Health

Emerged to describe the use of web-Emerged to describe the use of web-based sources that provide based sources that provide consumers with medical adviceconsumers with medical advice

Goals of TelehealthGoals of Telehealth Increase AccessIncrease Access

• Distance from facilityDistance from facility• Lack of specialistsLack of specialists• Lack of transportationLack of transportation

Services in natural environmentServices in natural environment Continuity of CareContinuity of Care Increase ComplianceIncrease Compliance Enhanced OutcomesEnhanced Outcomes Decrease Costs (Whose?)Decrease Costs (Whose?)

• TravelTravel• Time off workTime off work• Child careChild care

FormatsFormats

Clinician to PatientClinician to Patient Clinician to ClinicianClinician to Clinician

HistoryHistory

Before 1900 Before 1900 • African villagers used smoke signals to African villagers used smoke signals to

warn people to stay away from the warn people to stay away from the village in case of serious diseasevillage in case of serious disease

1906 ECG transmission over 1906 ECG transmission over telephone linestelephone lines

1920’s linking physicians to ships by 1920’s linking physicians to ships by radioradio

1924 First Exposition of Telecare1924 First Exposition of Telecare

1955 Telepsychiatry1955 Telepsychiatry• The Nebraska Psychiatric Institute was one of the first The Nebraska Psychiatric Institute was one of the first

facilities in the country to have closed-circuit TV.facilities in the country to have closed-circuit TV. 1960’s NASA1960’s NASA

• Monitoring health of astronauts via satelliteMonitoring health of astronauts via satellite 1967 Mass General1967 Mass General

• Occupational health services to airport employees and Occupational health services to airport employees and to deliver emergency care to travelersto deliver emergency care to travelers

1970 Satellite Telemedicine1970 Satellite Telemedicine• linking parametics in remote Alaskan and Canadian linking parametics in remote Alaskan and Canadian

villages to distant hospitalsvillages to distant hospitals 1977 Memorial University of Newfoundland1977 Memorial University of Newfoundland

• Province-wide teleconferencing systemProvince-wide teleconferencing system

1984 North-West Telemedicine Project1984 North-West Telemedicine Project• Australian satellite communications network; Australian satellite communications network;

health care in remote townshealth care in remote towns 1989 NASA SpaceBridge to Armenia1989 NASA SpaceBridge to Armenia

• Medical consultation following a devastating Medical consultation following a devastating earthquakeearthquake

1998 NIDRR 1998 NIDRR • funded the first RERC on tele-rehabilitationfunded the first RERC on tele-rehabilitation• 2004 the second RERC was awarded to 2004 the second RERC was awarded to

University of PittsburghUniversity of Pittsburgh

Current Example ApplicationsCurrent Example Applications Monitoring Pace Maker function via telephone Monitoring Pace Maker function via telephone

(coupling provided)(coupling provided) Automated Telephone Disease Management Automated Telephone Disease Management

(ATDM)(ATDM)• Interactive patient follow-up assessmentsInteractive patient follow-up assessments• Convey health-promotion informationConvey health-promotion information

Piette et al (2000) showed significant Piette et al (2000) showed significant improvement on a number of patient-related improvement on a number of patient-related health outcomes in patients receiving telephone health outcomes in patients receiving telephone intervention as compared to those receiving intervention as compared to those receiving traditional care traditional care (you need to be able to hear on (you need to be able to hear on the phone)the phone)

Early Adopters of Current Early Adopters of Current TelehealthTelehealth

State penitentiary State penitentiary systemssystems

Rural health care Rural health care systemssystems

Radiology Radiology professionprofession

VAVA DoDDoD

What do our professional What do our professional organizations have to say?organizations have to say?

ASHA – Technical Report (2005)ASHA – Technical Report (2005) AAA – resolution (2008)AAA – resolution (2008)

• www.audiology.org/advocacy/publicpolicyresolwww.audiology.org/advocacy/publicpolicyresolutions/pages/default.aspxutions/pages/default.aspx

• WhereasWhereas• Resolved, that audiology Resolved, that audiology

telehealth/telemedicine services should be telehealth/telemedicine services should be validated before implementation to assure validated before implementation to assure confidentiality and accuracy as well as to confidentiality and accuracy as well as to evaluate feasibility, particularly with difficult to evaluate feasibility, particularly with difficult to test populations for which little or no validation test populations for which little or no validation or telehealth/telemedicine services currently or telehealth/telemedicine services currently exists.exists.

Cardinal RuleCardinal Rule

Must adhere to the same level of Must adhere to the same level of quality as services delivered face-to-quality as services delivered face-to-faceface

Subject to the same rulesSubject to the same rules• Code of EthicsCode of Ethics• Scope of PracticeScope of Practice• State and Federal Laws (licensure)State and Federal Laws (licensure)• HIPAA (privacy)HIPAA (privacy)

ASHA Code of EthicsASHA Code of Ethics

Clinical services provided solely by Clinical services provided solely by correspondence should not be correspondence should not be considered acceptable applications considered acceptable applications of telepractice.of telepractice.

AAA Code of EthicsAAA Code of Ethics

Nothing specific to telehealth Nothing specific to telehealth practicepractice

ASHA 2002 Survey (N=1,667)ASHA 2002 Survey (N=1,667)

12% of audiologists had provided 12% of audiologists had provided services via telehealth (mostly services via telehealth (mostly phone)phone)

Smaller percent used web-based or Smaller percent used web-based or videoconferencing technologyvideoconferencing technology

Direct patient care (50%)Direct patient care (50%) Professional consultation (35%)Professional consultation (35%) Education (5%)Education (5%) Supervision (5%)Supervision (5%)

Services Provided by Audiologists Services Provided by Audiologists (2002)(2002)

Counseling (83%)Counseling (83%) Follow up (68%)Follow up (68%) Equipment Check (47%)Equipment Check (47%) Treatment (14%)Treatment (14%)

New “clinical” competenciesNew “clinical” competencies

Knowledge of:Knowledge of:• The types and use of technology used The types and use of technology used

for delivering telepractice services, and for delivering telepractice services, and awareness of the remote client’s awareness of the remote client’s resources and support system.resources and support system.

• How to address cultural/linguistic How to address cultural/linguistic differences in client populations using differences in client populations using telepractice service deliverytelepractice service delivery

Ability to:Ability to:• Assess the appropriateness of clients as Assess the appropriateness of clients as

candidates for telepracticecandidates for telepractice• Match the appropriate technology to the Match the appropriate technology to the

clinical needs of the clientclinical needs of the client• Assure the reliability and validity of diagnoses Assure the reliability and validity of diagnoses

obtained via telepracticeobtained via telepractice• Adapt diagnostic procedures and treatment Adapt diagnostic procedures and treatment

techniques to the telepractice encountertechniques to the telepractice encounter• Assure the effectiveness of the telepractice Assure the effectiveness of the telepractice

encounterencounter• Document services approriatelyDocument services approriately

Three ModelsThree Models Store-and-forward (asynchronous)Store-and-forward (asynchronous)

• information is first recorded and then sent for information is first recorded and then sent for interpretation laterinterpretation later

• Typically conducted through email, voice mail, faxTypically conducted through email, voice mail, fax• Worth et al (1995) reported cost-effective use of email Worth et al (1995) reported cost-effective use of email

for consultationfor consultation Clinician Interactive (synchronous)Clinician Interactive (synchronous)

• Interactive video to supervise testing by a technician off Interactive video to supervise testing by a technician off site (providing diagnosis and recommended treatment)site (providing diagnosis and recommended treatment)

• Control of the offsite computer in real time (direct Control of the offsite computer in real time (direct interaction with patient)interaction with patient)

• Need for “technician”, “facilitator” on site with the Need for “technician”, “facilitator” on site with the patient?patient?

Self-Monitoring/TestingSelf-Monitoring/Testing

History of (reported) TeleaudiologyHistory of (reported) Teleaudiology

Fabry, 1996 – Mayo providing hearing aid Fabry, 1996 – Mayo providing hearing aid adjustments at a distance (synchronous)adjustments at a distance (synchronous)

Sullivan, 1997 reported video otoscopy at Sullivan, 1997 reported video otoscopy at a distance (synchronous)a distance (synchronous)

California, 2004 – interactive video to California, 2004 – interactive video to supervise a hearing aid dispenser and supervise a hearing aid dispenser and technician providing care in rural technician providing care in rural communities. Also provided auditory communities. Also provided auditory rehab via video. (synchronous)rehab via video. (synchronous)

History of (reported) TeleaudiologyHistory of (reported) Teleaudiology

Krumm et al (2005). Universal newborn Krumm et al (2005). Universal newborn screening in rural areas (synchronous)screening in rural areas (synchronous)

Ribera (2005). HINT at a distance Ribera (2005). HINT at a distance (synchronous).(synchronous).

Elangovan (2005). Pure tone testing and Elangovan (2005). Pure tone testing and OAEs (synchronous).OAEs (synchronous).

Towers et al (2005). Click-evoked and Towers et al (2005). Click-evoked and frequency specific ABR (synchronous)frequency specific ABR (synchronous)

Yates et al (2005). Audiovestibular Yates et al (2005). Audiovestibular education and serviceseducation and services

DizzinessDizziness NIH reports that 7 million new patients report to NIH reports that 7 million new patients report to

health care providers with a complaint of health care providers with a complaint of dizziness each yeardizziness each year

#1 complaint of patients over 70#1 complaint of patients over 70 1 in 3 people will have dizziness or balance 1 in 3 people will have dizziness or balance

disorder in their lifetimedisorder in their lifetime 85% are due to peripheral disorders85% are due to peripheral disorders Benign paroxysmal positional vertigo (BPPV) is Benign paroxysmal positional vertigo (BPPV) is

the most common cause of vertigo (>40 years of the most common cause of vertigo (>40 years of age)age)

Older populationOlder population• Far greater risk for dizzinessFar greater risk for dizziness• Over-represented in rural and remote areasOver-represented in rural and remote areas

Dizziness (Yates et al, 2005)Dizziness (Yates et al, 2005)

Web-based tutorial to teach VNG Web-based tutorial to teach VNG (videonystagmography)(videonystagmography)

Balance screening taught via Balance screening taught via telecommunicationstelecommunications

Franck and colleagues (2006) Franck and colleagues (2006) reported remote CI programming at reported remote CI programming at CHOPCHOP

Remote CI Remote CI mappingmapping

DoDDoD Private SectorPrivate Sector

Computer based clinical Computer based clinical applicationsapplications

AudiometersAudiometers ABRABR OAEsOAEs ImmittanceImmittance Hearing Aid Programming and Hearing Aid Programming and

MeasurementMeasurement Manufacturers are promoting Manufacturers are promoting

equipment with synchronous or equipment with synchronous or store-forward capabilitiesstore-forward capabilities

What constitutes Telehealth in What constitutes Telehealth in Audiology?Audiology?

LACELACE Trainable Hearing AidsTrainable Hearing Aids

Most Activity In…Most Activity In…

Prototypes that test clinical Prototypes that test clinical possibilitiespossibilities

Evaluating the utility and validity of Evaluating the utility and validity of new systems in a clinical settingnew systems in a clinical setting

Signs of Telehealth AdoptionSigns of Telehealth Adoption

Increased ubiquity of internet connectivity Increased ubiquity of internet connectivity • Ubiquitous – existing or being everywhere at Ubiquitous – existing or being everywhere at

the same time; constantly encounteredthe same time; constantly encountered Medical professionals showing technology Medical professionals showing technology

prowess (life long learners)prowess (life long learners) Health Care provider shortagesHealth Care provider shortages Legislative pressure and payer incentivesLegislative pressure and payer incentives

Ubiquitous?Ubiquitous?

Radio – 38 years to reach 50 million Radio – 38 years to reach 50 million usersusers

TV – 13 years to reach 50 million TV – 13 years to reach 50 million usersusers

Internet – 5 years to reach 50 million Internet – 5 years to reach 50 million usersusers

ReferencesReferences ASHA (2005). Audiologists providing clinical services via telepractice: technical report (working ASHA (2005). Audiologists providing clinical services via telepractice: technical report (working

group on Telepractice). group on Telepractice). www.asha.org/policywww.asha.org/policy Elangovan, S. (2005). Telehearing and the internet. Seminars in Hearing, 26(1), 19-25.Elangovan, S. (2005). Telehearing and the internet. Seminars in Hearing, 26(1), 19-25. Franck, K., Pengelly, M., Zerfoss, S. (2006). Telemedicine offers remote cochlear implant Franck, K., Pengelly, M., Zerfoss, S. (2006). Telemedicine offers remote cochlear implant

programming. Volta Voices, January/February, 16-19.programming. Volta Voices, January/February, 16-19. Krumm, M, Ribera, J., Schmeidge, J. (2005). Using a telehealth medium for objective hearing testing: Krumm, M, Ribera, J., Schmeidge, J. (2005). Using a telehealth medium for objective hearing testing:

implications for supporting rural universal newborn hearing screening programs. Seminars in implications for supporting rural universal newborn hearing screening programs. Seminars in Hearing, 26(1), 3-12.Hearing, 26(1), 3-12.

Mormer, E., Mack, A. (2003). Telephone across the life span: an issue for all. Seminars in Hearing, Mormer, E., Mack, A. (2003). Telephone across the life span: an issue for all. Seminars in Hearing, 24 (1), 1-16.24 (1), 1-16.

Office for the advancement of telemedicine. Dramatic consultations using telemedicine: Northern Office for the advancement of telemedicine. Dramatic consultations using telemedicine: Northern California Telemedicine Network (NCN) Santa Rosa Memorial Hospital (SRMH) Santa Rosa, CA. California Telemedicine Network (NCN) Santa Rosa Memorial Hospital (SRMH) Santa Rosa, CA. http://telehealth.hrsa.gov.grants/success.htm#aud.http://telehealth.hrsa.gov.grants/success.htm#aud.

Piette, J., Weinberger, M., McPhee, S. et al. (2000). Do automated calls with nurse follow-up improve Piette, J., Weinberger, M., McPhee, S. et al. (2000). Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? Am J Med, 108, 20-27.self-care and glycemic control among vulnerable patients with diabetes? Am J Med, 108, 20-27.

Ribera, J. (2005). Interjudge reliability and validation of telehealth applications of the hearing in Ribera, J. (2005). Interjudge reliability and validation of telehealth applications of the hearing in noise test. Seminars in Hearing, 26(1), 13-18.noise test. Seminars in Hearing, 26(1), 13-18.

Towers, A., Pisa, J., Froelich, T., Krumm, M. (2005). The reliability of click-evoked and frequency-Towers, A., Pisa, J., Froelich, T., Krumm, M. (2005). The reliability of click-evoked and frequency-specifi auditory brainstem resone teseting using telehealth technology. Seminars in Hearing, 26(1), specifi auditory brainstem resone teseting using telehealth technology. Seminars in Hearing, 26(1), 26-34.26-34.

Worth, E. Klimczak, P., Reid, J., (1995). Cost-effective clinical uses of wide-area networks: electronic Worth, E. Klimczak, P., Reid, J., (1995). Cost-effective clinical uses of wide-area networks: electronic mail as telehealth. Proceedings of the Annual Symposium on Computer Applications in Medical Care. mail as telehealth. Proceedings of the Annual Symposium on Computer Applications in Medical Care. 814-818.814-818.

Yates, J., Campbell, K. (2005). Audiovestibular education and services via telemedicine Yates, J., Campbell, K. (2005). Audiovestibular education and services via telemedicine technologies. Seminars in Hearing, 26(1), 35-42.technologies. Seminars in Hearing, 26(1), 35-42.