Using Technology and Tele-Audiology to Leverage our Resources and Expand Services

Author: Pamela Matthews, Au.D.

When asked how it was he scored so many goals and always seemed to be in the right place at the right time, Wayne Gretzky replied, “That’s because I skate to where the puck is going to be.” The audiology profession is facing an increasing array of business challenges. Declining reimbursement continues to put downward pressure on profitability. The number of hearing impaired individuals is expected to grow faster than the number of newly minted audiologists, and it seems most practices are already operating at capacity. There are also a number of new sales channels entering the market including big box retail stores, internet sales, manufacturer-owned dispensing practices, and even health insurance companies increasing competition and creating lower consumer price expectations.

In response to these challenges, we can continue to practice with the conventional delivery systems that have served us until now (equivalent to skating to where the puck is now not where it is going to be). Alternatively, we can create new paradigms to propel audiology forward and gain essential leverage. We need to consider optimized methods to create patient-centric, clinically appropriate, and profitable delivery models.

The charge for many audiologists is to maximize efficiency and improve practice economics, expand patient access and services, and effectively identify and treat prospective patients. First and foremost, we need to objectively review our practice productivity. Productivity can be defined as Output (typically revenue) per Unit Time (i.e. hour). The goal is to increase productivity for each associate within the practice, especially those who have the ability to perform the highest value added activities. Productivity may be affected by increasing output or sales and/or reducing the amount of time needed to accomplish the desired activity.

Analyzing workflow to define the potential value of each activity helps determine how to introduce technologies or processes that can increase productivity and improve the bottom line. For example, an audiologist performing a comprehensive audiometric examination might be reimbursed at the low end, an average of $40 by Medicare. Including the time required to acquire the case history, conduct testing and review results, a hearing test takes approximately 45 minutes. The value to the practice is about $60-100 per hour. On the other hand, a consultation that leads to a bilateral fitting may generate approximately $2,000 or more in net revenue (profit). If this process takes 5 hours (1 hour consult, 1 hour fitting, and 3 hours follow-up during warranty period), the value to the practice is $400 per hour or more. It becomes obvious that spending more time providing these high value-added activities will increase productivity and profitability.

While it would be nice if every activity generated $400, the reality is there are several lower value activities that are essential to patient care such as diagnostic testing. Other therapeutic areas, such as ophthalmology and optometry, radiology and pulmonology have all utilized two essential tools to improve productivity and profitability – assistants and technology. Technicians perform routine testing with sophisticated test equipment, usually automated for consistency and accuracy. The high value clinical professionals then interpret the test results and provide the diagnosis.

Since the methodology for threshold testing is well established and rules-based, i.e. Houghson-Westlake, sophisticated systems have been developed which allow technician administration of routine testing. Just as with ophthalmologists, radiologists and pulmonologists, the audiologist may then interpret the results, provide the diagnosis and, if necessary, use alternate methods to check or confirm the results. At that point, the clinician has the option to determine if additional testing is required prior to rendering a diagnosis. Utilizing technicians and technology for data gathering improves process flow and practice profitability by freeing up the specialized resource to spend time with patients engaged in higher-level activities. Savvy utilization of technicians and technology allows a practice to see more patients per day, while lowering costs and increasing margins.

In addition to improving efficiency, we can increase output or sales. Current estimates are that about one in 10 or approximately 30 million Americans experience hearing loss. Yet only 8 million currently wear hearing aids. This represents a largely untapped potential population. Patient acquisition tools including advertising, community outreach, building referral networks, corporate or government contracting, and patient word of mouth have traditionally identified prospective patients. In spite of utilizing all of these tools, the number of hearing aid wearers has not been significantly impacted. With more supply outlets competing for the same patient population, we need to attract new patients to maintain and substantially more to grow. If we did manage to attract even twice the number of current hearing aid wearers, would our current models be able to accommodate the growth? What delivery models will be best suited to take advantage of this opportunity?

With a chronic shortage of audiologists and the potential increase in the number of hearing impaired, how can we reach out to these prospective patients efficiently and effectively? Implementing intelligent technologies allows audiologists and other hearing health professionals to improve workflow and focus on patient interactions. The use of tele-audiology in combination with technologies can be utilized to leverage resources and improve access to patients.

Many words are used to describe the use of telecommunications in the practice of medicine. Tele-health, tele-medicine, tele-audiology. Telehealth is the use of telecommunications and IT in any area of healthcare, including prevention, medical intervention, education, administration and advocacy. Telemedicine is direct medical interaction through telecommunication channels. Tele-audiology is the direct application of telemedicine infrastructures for the practice of audiology.

Tele-audiology has generally been perceived as a vehicle for humanitarian efforts in underserved areas of the world and remote areas of the U.S. It hasn’t been widely adopted in large part due to the difficulty of adapting today’s equipment to the task. Most efforts have attempted to use existing tools in the same way, but over new communication channels. For instance, previous attempts to conduct audiometric testing over the internet have used conventional PC based audiometers on the patient’s end with a remote audiologist operating the PC audiometer via a program such as PC Anywhere. This method has significant limitations. It requires the patient and audiologist to be present at the same time and to be connected via videoconferencing. Both videoconferencing and remote PC access are constrained by bandwidth access and speed. Invariably, it is challenging to determine if a patient is responding to the stimulus in a timely manner. Speech testing is challenging even if recorded material is used at the test site as the accuracy of the test can only be as good as the quality of the audio connection. At best, such testing takes substantially longer than in a conventional setting to obtain a quality outcome.

The fact is that conventional systems were not designed for tele-audiology. What is needed is to think about the specific needs and desired outcomes for an application, and then develop technologies and equipment to meet those needs.

In the case of tele-audiometry, we want to have a system that can accurately and reliably test patients in a remote environment but is not constrained by bandwidth and transmission speeds. The optimal way to do this is to have the audiometer system located at the patient site without the need to control it from a remote site during the testing.

Using today’s innovative technologies, such as automated diagnostic tools, all-in-one diagnostic and video-conferencing systems, such as the Otogram and OtoConnect, offer the ability to reduce the cost to administer audiology services and increases the opportunity for direct patient access to audiology. Whether working with satellite offices in urban and suburban areas or with rural outreaches, tele-audiology is a bridge to improved patient access and quality care.

Tele-audiology using today’s innovative technologies leverages the power of video conferencing and information systems to enable patients, audiologists, allied health professionals and physicians to see and talk to each other live, review test results, and determine the next step in the course of clinical treatment. Potential applications include remote assessment of the patient including otoscopic evaluation, diagnostic testing, hearing aid fitting and programming, site supervision and staff training. In some environments we can envision the option for home-based patient encounters for hearing aid counseling with family members, hearing aid follow-up care, and facilitated auditory or tinnitus management.

Harnessing tele-audiology is possible using automated and computer-assisted diagnostics and well-supervised audiology technicians in combination with telecommunication systems. Implementing a tele-audiology component to a practice can help us improve patient flow, increase the number of patients seen, and increase overall cash flow by having more time to counsel and dispense hearing solutions.

Scenario A
Audiology practices with multiple locations often are not fully staffed at every location on every day. In practices with audiologists that drive from location to location, the use of tele-audiology can provide a unique opportunity. Envision the ability to supervise remotely the administration of a diagnostic hearing test using testing parameters defined by the audiologist. The audiology assistant administers the test and the audiologist at the flagship practice interprets the result. Following the test, the audiologist engages in a face to face conversation with the patient to discuss the results of the test and the treatment options. Rapport builds between the patient, audiologist, and clinic personnel. The patient may be scheduled at the flagship practice or at the satellite practice for a hearing aid fitting. Now, when the audiologist visits the satellite, their valuable audiology time is spent providing hearing aid consults and fittings, rather than diagnostics. Engaging in high value activities equals greater profitability.

Scenario B
The audiologist is located at the primary practice site and visits referral sites periodically for both diagnostic hearing tests and hearing aid fittings. A patient in the referral site would like to discuss his hearing aid programming and can’t or won’t drive to the primary office location. For patient convenience and service, the audiologist schedules a tele-audiology encounter with the patient. The interaction between the patient and the audiologist is real time, face to face. A technician at the referral site, either associated with the audiologist or the practice, acts as the “hands” for the audiologist. The technician “preps” the patient, attaching the hearing aid cables to the devices, and ensuring the patient is comfortable. The audiologist remotely controls the fitting equipment at the patient site and fine tunes the hearing aids. The relationship between audiologist and patient blossoms and both see benefit from the convenient access.

Scenario C
The audiology practice establishes patient identification technology in a Primary Care Physician practice to improve early identification and treatment of hearing loss. The hearing screening is self-administered and the results are reported to the physician or nursing staff to discuss with the patient. When a patient fails the screening, the need for a diagnostic evaluation is indicated and communicated. The audiologist may be contacted in real time or scheduled for a remote consult at either the audiology practice or the referral site to discuss the need for diagnostic testing. Further, it is possible to have the physician practice schedule testing and consults, in advance, based on the outcome of screening. More patients are identified with hearing loss and begin the process of considering treatment options.

Telemedicine in general and tele-audiology in particular require specific considerations. Implementing tele-audiology programs requires a knowledge of and adherence to federal and state regulatory and licensing requirements for patient interaction and supervision. Audiologists must provide the same level of care and maintain ethical and professional standards in accordance with state laws.

Additional considerations regarding Medicare or insurance reimbursement, telecommunications equipment and connectivity, and implementation strategies are also important elements to include in the decision to employ tele-audiology components in the practice.

The Future
Tele-audiology in conjunction with compatible technologies offers a new path to expand access and services to patients while easing costs and simplifying logistics. The audiology landscape is changing at a palpable pace. The demand for service is growing, audiology resources are scarce, reimbursement is anemic and competition is fierce. Many audiologists are finding that they can either allow market forces to redefine their role in hearing healthcare or proactively create new processes that increase productivity and profitability to the benefit of audiologists, their businesses and, most important, the patient.    
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