Teleaudiology jackson hole

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Teleaudiology jackson hole

  1. 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. 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. 3. Tele…Tele…  Far or DistantFar or Distant  Care at a distanceCare at a distance • In absentia careIn absentia care
  4. 4. Raise your hand if you haveRaise your hand if you have participated in Telehealth asparticipated in Telehealth as a provider.a provider.
  5. 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. 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. 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. 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. 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. 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. 11. FormatsFormats  Clinician to PatientClinician to Patient  Clinician to ClinicianClinician to Clinician
  12. 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. 13. 1924 First Exposition of Telecare1924 First Exposition of Telecare
  14. 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. 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. 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. 17. Early Adopters of CurrentEarly Adopters of Current TelehealthTelehealth  State penitentiaryState penitentiary systemssystems  Rural health careRural health care systemssystems  RadiologyRadiology professionprofession  VAVA  DoDDoD
  18. 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. 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. 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. 21. AAA Code of EthicsAAA Code of Ethics  Nothing specific to telehealth practiceNothing specific to telehealth practice
  22. 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. 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. 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. 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. 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. 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. 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. 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. 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. 31.  Franck and colleagues (2006)Franck and colleagues (2006) reported remote CI programming atreported remote CI programming at CHOPCHOP
  32. 32.  Remote CIRemote CI mappingmapping  DoDDoD  Private SectorPrivate Sector
  33. 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. 34. What constitutes Telehealth inWhat constitutes Telehealth in Audiology?Audiology?  LACELACE  Trainable Hearing AidsTrainable Hearing Aids
  35. 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. 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. 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. 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.

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