How to Implement Tele-Audiology: Best Practices for a New Paradigm



Author: Anna McCraney, Au.D. and Beth Spearman

“The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.”
—Albert Einstein

The perfect storm is brewing for audiology practices across the country. Some practices heeded the warnings early, knowing that at the intersection of scarce audiology resources, burgeoning patient populations and anemic reimbursement it would be critical to employ technology to meet the need and not only stay solvent, but thrive. While not for the faint of heart, the next few years could allow audiologists to define a new paradigm in the delivery of hearing health excellence.

With these challenges upon us, audiologists can and should investigate new methods of doing business to prosper. Introducing tele-audiology services in a practice can lead to enhanced business opportunities and, potentially, the ability to compete in a different way with the new sales channels in the marketplace, including big box retail stores, internet sales, and health insurance companies. It might also lead to shared care opportunities between audiology, ENT and family practices.

Tele-audiology by definition is the direct application of telemedicine principals for the practice of audiology. This might include consultations with patients or clinicians, audiometric testing and interpretation, device programming, supervision and e-training, patient education and advocacy. The American Telemedicine Association estimates the number of existing telemedicine networks in the United States at roughly 200 providing connectivity to over 3,000 sites. The two most common types of tele-audiology are synchronous (live interactive encounter) and asynchronous (store and forward).

Practical Applications
There are as many different ways to implement tele-audiology as there are clinical practices. While it isn’t possible or even necessary to outline every application, we can share a few of the challenges we’ve faced and the tele-audiology solutions that proved effective.

Challenge: No audiologist or dispenser available at clinic
Tele-audiology Solution: Utilize a technician and tele- audiology to dispense with audiologist at off-site location

We were consulted by a Florida ENT who needed to be able to provide hearing aid services, but had been unable to secure an audiologist or dispenser. With the programming equipment (software and cables) and telemedicine equipment (webcam and videoconferencing software) local to the practice, we were able to demonstrate how an audiologist 1000 miles away could complete a hearing aid fitting with the help of an assistant. The assistant roomed the patient, connected the new aids to the programming software and the patient, and facilitated the remote connection. Remote computer access including an audiovisual connection allowed the patient and me to see and talk to each other while I drove the fitting software. I was able to complete both unaided and aided in situ testing, program the aids, and save all the information to the patient’s file as if I’d been in the same room with her. The patient, well into her 70’s, commented, “Isn’t technology great?” She left the office grateful that it hadn’t been necessary for her to drive to a neighboring town to get fitted with new aids. The ENT was able to see that he could expand his search for an audiologist to farther reaches, knowing that telemedicine would close the gap.

This happened to be an ENT in Florida, but we hear this from ENTs all over. The most common issue is not being able to find an audiologist in their area. This should be a loud wake-up call to audiologists who can clearly expand their catchment area through the offering of shared care programs and the adoption of telemedicine practices. Audiologists can drive this process with both ENTs and other practitioners.

It is worth noting that tele-medicine laws are not yet well-defined, leaving a lot open to interpretation. Thinking it better to err on the conservative side, being licensed in the state where the patient appointment occurs has been our practice. As such, I am licensed in eight states, including Florida.

Challenge: Hub and spoke system where patient and provider are at different locales
Tele-audiology Solution: Store and forward data share and real time interaction between offices

I am the Director of Audiology at The Glasscock Hearing Implant Center in Houston, TX. Proprietor and surgeon, Dr. Michael Glasscock lives in Austin, TX and has frequent speaking engagements all over the world. As such, he is not always in the clinic. He does, however, always have his computer with him so we connect using telemedicine applications as needed.

Whether it is the initial visit for an implant evaluation, or a follow-up visit, the patient has an opportunity for a face-to-face encounter with the otologist. The video conferencing capabilities allow me to introduce the patient during an initial implant consult and summarize case history and test results, while screen sharing the audiometric data and the otoscopic images. He is then able to review the clinical information and discuss the options with the patient, and continue the counseling discussion regarding surgical candidacy and expectations.

Patients, regardless of age and affinity for technology, can all appreciate the convenience of not requiring multiple visits and still being able to have a face-to-face encounter. They liken it to FaceTime with family.

Another environment we’ve seen where tele-audiology makes sense is in practices with satellite offices. So often, we hear commuting horror stories with audiologists having to cover multiple clinics per week or other irregular intervals. It never fails that a patient will show up as a walk-in to a clinic the day after the audiologist was just there. Whether a new or established patient, the ability to have a face to face encounter can mean the difference between retaining or losing the patient. Often they have a “pressing” concern so they don’t want to be put off until the next time the audiologist rotates through that location, yet they also don’t want to drive across town to whichever office the audiologist is in that day. Many times the issue is something that can be fixed in moments, like device troubleshooting or a quick programming adjustment. It’s practical for both the patient and the audiologist if the issue can be addressed easily without anyone having to drive across town. It also creates goodwill and great distinction when the audiologist is immediately responsive to patient needs. Tele-audiology allows this and only requires “hired hands” in the form of an assistant or facilitator.

Challenge: Supply and demand discrepancy
Tele-audiology Solution: Utilizing technicians and automated audiometry (audioliogist can control, supervise and/or interpret data from anywhere)

To accomplish more with less, these practices have hired audiology assistants and procured automated audiometers to control the cost of triage. In this scenario, technicians gather basic audiometric data that the audiologists evaluate before designating a treatment pathway. For example, with automated audiometry the audiologist defines the protocol, trains the technicians or clinical assistants to administer the testing, may supervise the process remotely and evaluate the results from anywhere. Threshold detection lends itself well to automation as it is simply the automation of the rules-based industry accepted algorithms, i.e. modified Hughson Westlake.

This scenario is both responsible and efficacious. Optimizing the process frees audiologists to work to the top of their licensure by dedicating their expertise where it is needed. So, rather than spending time conducting routine audiometry, they can concentrate on more comprehensive diagnostics, treatment and counseling. It is efficacious in that one technician can run 3-4 automated audiometers at a time, increasing throughput and ensuring that the patients that need a medical consult or a surgical treatment option get routed to ENT, while the ones that need amplification get routed to Audiology. This has proven to be an efficient way to make sure each patient follows the most direct route to the most appropriate treatment.

Best Practices
There are several contributing factors to the successful launch of a tele-audiology practice, including strategic planning, infrastructure, legal and regulatory considerations, reimbursement and availability of development and operational resources.

Creating an effective tele-audiology program requires careful planning and a thoughtful implementation strategy. Understanding the strategic objectives is critical. Based on the practice’s location, demographics, and business goals, determine what services would provide value. What are the priorities for growth, clinical services and reputation? What metrics will measure progress and success? How will you define the return on investment and how will it be quantified? Examine what it is that the practice provides that makes your patients loyal. Look at the competitive market and determine what others do that you might be able to enhance with new techniques. What opportunities exist to grow partnerships and your overall access to patients for a variety of audiology services, be it hearing aids, implants, balance, etc.?

Once the objective and goals have been determined, the next step is determining the tools required to execute the program to the desired scale. The essential tools required are bandwidth and connectivity, a video conferencing system, cameras at each location and personnel who can support the technology. There are a number of telemedicine interfaces that meet the criteria for HIPAA and HITECH. It is worthwhile to invest in good equipment, particularly due to the communication challenges inherent with hearing loss. Good audio-visual feed allows patients to capitalize on speech understanding and visual cues. It needs to be a reasonable surrogate for a face-to-face encounter. Poor fidelity and a pixelated screen will undermine the experience. After all, the implementation is only as good as the foundation it rests on.

View the equipment needs through the prism of your strategic objectives. In addition to the basic equipment, additional tools are required, including video otoscopes, audiometers (automated or otherwise), and EMR systems accessible through the cloud. Some of your existing audiology tools may be adapted to the tele-audiology practice, however, be realistic about how much you wish to accomplish and in what setting, i.e. satellite office or new relationships with a medical practice or hospital system.

No tele-audiology practice is complete without an analysis of the legal and regulatory landscape. Considerations include compliance with HIPAA, HITECH, and protection of patient information, licensure, scope of practice, and state and federal laws regulating telemedicine practice. ASHA has state tele-health requirements on their website: www.asha.org/Advocacy/state/State-Telepractice-Requirements.

Reimbursement is tricky for tele-health in general, let alone tele-audiology. More and more states, however, have legislated mandates for private coverage of tele-health services. As the economic advantages become clear and access to care improves, it is likely states will continue to legislate coverage. Contact your payors and investigate the reimbursement in your area.

Medicare has not traditionally covered tele-health. A new bill going to Congress to roll in Medicare coverage for tele-health, sponsored by Representatives Mike Thompson (D-Calif.) and Glenn Thompson (R-Penn), hopes to change that. The Medicare Tele-health Parity Act of 2014, is more measured, expanding the reach of Medicare in tele-health slowly over four years and establishing efficacy data requirements along the way. (MobiHealthNews July 23, 2014)

Whether or not services are reimbursed, good business practice would suggest analyzing the overall benefits of providing tele-audiology services. Fee for service rates, concierge medicine contracts or simply the promise of the financial benefit, stemming from increased device sales and an expanding patient base may augment or justify the investment.

Both AAA and ASHA have position statements in support of telemedicine practices but there are also many other resources in the telemedicine arena to draw upon for support. The American Telemedicine Association provides a wealth of information (www.americantelemed.org). In addition, regional resource centers provide development and implementation support.

A paucity of resources and reimbursement, coupled with a plethora of patients, is the reality of audiologists in practice today. The obligation to provide hearing health excellence is not excused by the challenges we face. Fortunately, technology is on our side. Tools exist to help us increase productivity and provide diagnostic and treatment service to patients even if we’re not in the same place at the point of contact.

Implementing a tele-audiology component can seem daunting, but can be worth the effort. We can’t alter the reality, but we will need to find a way to leverage our resources. Audiologists have the opportunity at this juncture to write a new chapter in their professional future. For many, tele-audiology will be part of the story.    
Anna McCraney, Au.D., is Director of Audiology at Ototronix and can be contacted at amccraney@ototronix.com.

Beth Spearman is Director of Business Development at Ototronix and can be reached at bspearman@ototronix.com.
Regional Resource Centers
California Telehealth Resource Center: www.caltrc.org
Northeast Telehealth Resource Center: www.netrc.org
Heartland Telehealth Resource Center: www.heartlandtrc.org
Southwest Telehealth Resource Center: www.southwesttrc.org
Northwest Telehealth Resource Center: www.nrtc.org
Midatlantic Telehealth Resource Center: www.matrc.org
Southeaster Telehealth Resource Center: www.setrc.org
TexLa Telehealth Resource Center: www.texlatrc.org
Upper Midwest Telehealth Resource Center: www.umtrc.org
Pacific Basic Telehealth Resource Center: www.pbtrc.org