1. Telehealth,Telehealth,
Telemedicine, TelerehabTelemedicine, Telerehab
Where does Audiology Stand andWhere does Audiology Stand and
Where are We Headed?Where are We Headed?
Catherine PalmerCatherine Palmer
University of PittsburghUniversity of Pittsburgh

2. 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 ofThere were 8000 cars and 144 miles of
paved roadspaved roads
 Maximum speed limit in most cities was 10Maximum 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 High6% of Americans graduated from High
SchoolSchool
 2 of 10 adults couldn’t read or write2 of 10 adults couldn’t read or write

3. Tele…Tele…
 Far or DistantFar or Distant
 Care at a distanceCare at a distance
• In absentia careIn absentia care

4. Raise your hand if you haveRaise your hand if you have
participated in Telehealth asparticipated in Telehealth as
a provider.a provider.

5. Agency for Healthcare ResearchAgency for Healthcare Research
and Qualityand Quality
 Telemedicine is the use ofTelemedicine is the use of
telecommunications technology fortelecommunications technology for
medical diagnostic, monitoring, andmedical diagnostic, monitoring, and
therapeutic purposes when distancetherapeutic purposes when distance
separates the users.separates the users.

6. Telehealth Act (1996)Telehealth Act (1996)
 ……encouraged a greater variety ofencouraged a greater variety of
services by all health professionalsservices by all health professionals
 Telehealth is the provision of healthTelehealth is the provision of health
services from one location to anotherservices from one location to another
using a computer network, theusing a computer network, the
internet, telephone, or otherinternet, telephone, or other
telecommunication mediumstelecommunication mediums

7. DefinitionsDefinitions
 The term telepractice has beenThe term telepractice has been
adopted to encompass both theadopted to encompass both the
delivery of clinical services and thedelivery of clinical services and the
provision of health-relatedprovision of health-related
information…information…

8. Popular DefinitionsPopular Definitions
 Right care at the right time in theRight care at the right time in the
right place (VA)right place (VA)
 There’s been a realization that theThere’s been a realization that the
exam room is wherever the patientexam room is wherever the patient
is…(Jay Sanders, MD)is…(Jay Sanders, MD)

9. E-HealthE-Health
 Emerged to describe the use of web-Emerged to describe the use of web-
based sources that providebased sources that provide
consumers with medical adviceconsumers with medical advice

10. 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

11. FormatsFormats
 Clinician to PatientClinician to Patient
 Clinician to ClinicianClinician to Clinician

12. HistoryHistory
 Before 1900Before 1900
• African villagers used smoke signals toAfrican villagers used smoke signals to
warn people to stay away from thewarn people to stay away from the
village in case of serious diseasevillage in case of serious disease
 1906 ECG transmission over1906 ECG transmission over
telephone linestelephone lines
 1920’s linking physicians to ships by1920’s linking physicians to ships by
radioradio

13. 1924 First Exposition of Telecare1924 First Exposition of Telecare

14.  1955 Telepsychiatry1955 Telepsychiatry
• The Nebraska Psychiatric Institute was one of the firstThe 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 toOccupational health services to airport employees and to
deliver emergency care to travelersdeliver emergency care to travelers
 1970 Satellite Telemedicine1970 Satellite Telemedicine
• linking parametics in remote Alaskan and Canadianlinking 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

15.  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 devastatingMedical consultation following a devastating
earthquakeearthquake
 1998 NIDRR1998 NIDRR
• funded the first RERC on tele-rehabilitationfunded the first RERC on tele-rehabilitation
• 2004 the second RERC was awarded to2004 the second RERC was awarded to
University of PittsburghUniversity of Pittsburgh

16. Current Example ApplicationsCurrent Example Applications
 Monitoring Pace Maker function via telephoneMonitoring Pace Maker function via telephone
(coupling provided)(coupling provided)
 Automated Telephone Disease ManagementAutomated 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 significantPiette et al (2000) showed significant
improvement on a number of patient-relatedimprovement on a number of patient-related
health outcomes in patients receiving telephonehealth outcomes in patients receiving telephone
intervention as compared to those receivingintervention as compared to those receiving
traditional caretraditional care (you need to be able to hear on(you need to be able to hear on
the phone)the phone)

17. Early Adopters of CurrentEarly Adopters of Current
TelehealthTelehealth
 State penitentiaryState penitentiary
systemssystems
 Rural health careRural health care
systemssystems
 RadiologyRadiology
professionprofession
 VAVA
 DoDDoD

18. What do our professionalWhat 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/publicpolicyresolutionwww.audiology.org/advocacy/publicpolicyresolution
• WhereasWhereas
• Resolved, that audiologyResolved, that audiology
telehealth/telemedicine services should betelehealth/telemedicine services should be
validated before implementation to assurevalidated before implementation to assure
confidentiality and accuracy as well as toconfidentiality and accuracy as well as to
evaluate feasibility, particularly with difficult toevaluate feasibility, particularly with difficult to
test populations for which little or no validationtest populations for which little or no validation
or telehealth/telemedicine services currentlyor telehealth/telemedicine services currently
exists.exists.

19. Cardinal RuleCardinal Rule
 Must adhere to the same level ofMust 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)

20. ASHA Code of EthicsASHA Code of Ethics
 Clinical services provided solely byClinical services provided solely by
correspondence should not becorrespondence should not be
considered acceptable applications ofconsidered acceptable applications of
telepractice.telepractice.

21. AAA Code of EthicsAAA Code of Ethics
 Nothing specific to telehealth practiceNothing specific to telehealth practice

22. ASHA 2002 Survey (N=1,667)ASHA 2002 Survey (N=1,667)
 12% of audiologists had provided12% of audiologists had provided
services via telehealth (mostlyservices via telehealth (mostly
phone)phone)
 Smaller percent used web-based orSmaller 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%)

23. Services Provided by AudiologistsServices 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%)

24. New “clinical” competenciesNew “clinical” competencies
 Knowledge of:Knowledge of:
• The types and use of technology usedThe types and use of technology used
for delivering telepractice services, andfor delivering telepractice services, and
awareness of the remote client’sawareness of the remote client’s
resources and support system.resources and support system.
• How to address cultural/linguisticHow to address cultural/linguistic
differences in client populations usingdifferences in client populations using
telepractice service deliverytelepractice service delivery

25.  Ability to:Ability to:
• Assess the appropriateness of clients asAssess the appropriateness of clients as
candidates for telepracticecandidates for telepractice
• Match the appropriate technology to the clinicalMatch the appropriate technology to the clinical
needs of the clientneeds of the client
• Assure the reliability and validity of diagnosesAssure the reliability and validity of diagnoses
obtained via telepracticeobtained via telepractice
• Adapt diagnostic procedures and treatmentAdapt diagnostic procedures and treatment
techniques to the telepractice encountertechniques to the telepractice encounter
• Assure the effectiveness of the telepracticeAssure the effectiveness of the telepractice
encounterencounter
• Document services approriatelyDocument services approriately

26. Three ModelsThree Models
 Store-and-forward (asynchronous)Store-and-forward (asynchronous)
• information is first recorded and then sent forinformation 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 emailWorth 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 offInteractive 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 (directControl of the offsite computer in real time (direct
interaction with patient)interaction with patient)
• Need for “technician”, “facilitator” on site with theNeed for “technician”, “facilitator” on site with the
patient?patient?
 Self-Monitoring/TestingSelf-Monitoring/Testing

27. History of (reported) TeleaudiologyHistory of (reported) Teleaudiology
 Fabry, 1996 – Mayo providing hearing aidFabry, 1996 – Mayo providing hearing aid
adjustments at a distance (synchronous)adjustments at a distance (synchronous)
 Sullivan, 1997 reported video otoscopy atSullivan, 1997 reported video otoscopy at
a distance (synchronous)a distance (synchronous)
 California, 2004 – interactive video toCalifornia, 2004 – interactive video to
supervise a hearing aid dispenser andsupervise a hearing aid dispenser and
technician providing care in ruraltechnician providing care in rural
communities. Also provided auditorycommunities. Also provided auditory
rehab via video. (synchronous)rehab via video. (synchronous)

28. History of (reported) TeleaudiologyHistory of (reported) Teleaudiology
 Krumm et al (2005). Universal newbornKrumm et al (2005). Universal newborn
screening in rural areas (synchronous)screening in rural areas (synchronous)
 Ribera (2005). HINT at a distanceRibera (2005). HINT at a distance
(synchronous).(synchronous).
 Elangovan (2005). Pure tone testing andElangovan (2005). Pure tone testing and
OAEs (synchronous).OAEs (synchronous).
 Towers et al (2005). Click-evoked andTowers et al (2005). Click-evoked and
frequency specific ABR (synchronous)frequency specific ABR (synchronous)
 Yates et al (2005). AudiovestibularYates et al (2005). Audiovestibular
education and serviceseducation and services

29. DizzinessDizziness
 NIH reports that 7 million new patients report toNIH reports that 7 million new patients report to
health care providers with a complaint ofhealth 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 balance1 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) isBenign paroxysmal positional vertigo (BPPV) is
the most common cause of vertigo (>40 years ofthe 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

30. Dizziness (Yates et al, 2005)Dizziness (Yates et al, 2005)
 Web-based tutorial to teach VNGWeb-based tutorial to teach VNG
(videonystagmography)(videonystagmography)
 Balance screening taught viaBalance screening taught via
telecommunicationstelecommunications

31.  Franck and colleagues (2006)Franck and colleagues (2006)
reported remote CI programming atreported remote CI programming at
CHOPCHOP

32.  Remote CIRemote CI
mappingmapping
 DoDDoD
 Private SectorPrivate Sector

33. Computer based clinicalComputer based clinical
applicationsapplications
 AudiometersAudiometers
 ABRABR
 OAEsOAEs
 ImmittanceImmittance
 Hearing Aid Programming andHearing Aid Programming and
MeasurementMeasurement
 Manufacturers are promotingManufacturers are promoting
equipment with synchronous orequipment with synchronous or
store-forward capabilitiesstore-forward capabilities

34. What constitutes Telehealth inWhat constitutes Telehealth in
Audiology?Audiology?
 LACELACE
 Trainable Hearing AidsTrainable Hearing Aids

35. Most Activity In…Most Activity In…
 Prototypes that test clinicalPrototypes that test clinical
possibilitiespossibilities
 Evaluating the utility and validity ofEvaluating the utility and validity of
new systems in a clinical settingnew systems in a clinical setting

36. Signs of Telehealth AdoptionSigns of Telehealth Adoption
 Increased ubiquity of internet connectivityIncreased ubiquity of internet connectivity
• Ubiquitous – existing or being everywhere atUbiquitous – existing or being everywhere at
the same time; constantly encounteredthe same time; constantly encountered
 Medical professionals showing technologyMedical 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

37. Ubiquitous?Ubiquitous?
 Radio – 38 years to reach 50 millionRadio – 38 years to reach 50 million
usersusers
 TV – 13 years to reach 50 millionTV – 13 years to reach 50 million
usersusers
 Internet – 5 years to reach 50 millionInternet – 5 years to reach 50 million
usersusers

38. ReferencesReferences
 ASHA (2005). Audiologists providing clinical services via telepractice: technical report (workingASHA (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 implantFranck, 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 hearingKrumm, M, Ribera, J., Schmeidge, J. (2005). Using a telehealth medium for objective hearing
testing: implications for supporting rural universal newborn hearing screening programs. Seminarstesting: implications for supporting rural universal newborn hearing screening programs. Seminars
in Hearing, 26(1), 3-12.in 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: NorthernOffice 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-upPiette, 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,improve self-care and glycemic control among vulnerable patients with diabetes? Am J Med, 108,
20-27.20-27.
 Ribera, J. (2005). Interjudge reliability and validation of telehealth applications of the hearing inRibera, 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: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 inelectronic mail as telehealth. Proceedings of the Annual Symposium on Computer Applications in
Medical Care. 814-818.Medical Care. 814-818.
 Yates, J., Campbell, K. (2005). Audiovestibular education and services via telemedicineYates, 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.