eAudiology: Shifting from Theory to Practice

Patient Care | September 2018 Hearing Review

A consensus statement on recommendations for telehealth practices in hearing healthcare

By Joseph Montano, EdD; Gina Angley, AuD; Colleen Ryan-Bane, MS; William Campbell, MClSc; Robert Eikelboom, PhD; Andrea Gerlach, AuD; Danielle Glista, PhD; Karen Muñoz, EdD; Christine Jones, AuD; Melanie Ferguson, PhD; De Wet Swanepoel, PhD; Ora Buerkli-Halevy, MS; Gurjit Singh, PhD; Davina Omisore, MSc; Martina Schuepbach-Wolf, and Francois Julita, MS, MBE

Technological innovations built on connectivity and smart technology (eg, Uber, Airbnb, Netflix) have proven to be powerful, disruptive forces in several fields, upending traditional business models and challenging the status quo. Similarly, there is a digital transformation occurring in healthcare that is having a profound effect on clinical practice and patient care. For example, a recent study of US hospitals and health systems found that 76% of hospitals have or will be implementing telehealth programs by December 2018.¹

The aim of this consensus statement is to provide recommendations to hearing care providers for integrating eAudiology into their existing practice as a means to reach new patients, enhance patient care, and increase the value of their services. It is the result of an Expert Panel convened by Phonak in January 2018.  

This shift toward technologically connected healthcare is driven partly by changes in society, in which people are more involved, questioning, and wanting more autonomy with regards to their healthcare.^2,3 In addition, with new government regulations and more device and service delivery options available for patients (eg, increased presence of over-the-counter products in various fields⁴), clinicians and health systems are obliged to re-evaluate traditional methods of delivering healthcare to consumers.

Alongside the transformations in mobile technology and connectivity capabilities, the modern patient landscape is also changing. Increasingly, patients are more assertive, health conscious, and engaged in their care.^5,6 Furthermore, they are embracing new technology and are increasingly tech-savvy. In the United States, estimates by Pew Research Center in 2017 noted that 42% of adults age 65 years or older reported smartphone ownership, suggesting that smartphone ownership is not restricted to younger adults.⁷ Similar reports are seen in other countries, such as the UK, with 65% of people between the ages of 65 and 75 being smartphone adopters.⁸

Clinical implementation of eAudiology has the potential to enhance services provided to clients/patients. Despite the advent of digital solutions for patients in healthcare overall, adoption of such solutions in audiology clinical practice remains low. A recent survey of audiologists found that even though positive attitudes towards telehealth and associated technologies were common, only 15.6% had utilized teleaudiology.⁹ 

This consensus paper is designed to help align terminology used to describe remote delivery of care, and discuss benefits and barriers to eAudiology, as well as some options available for hearing care professionals.

The Evolution of Terminology

With the development of technology in healthcare, the terminologies used to describe remote delivery of health services has been evolving to expand the reach of the practice (Figure 1). The terms “telehealth” and “telemedicine” have been used interchangeably to describe remote delivery of healthcare services and clinical information using various types of telecommunications technology.^10,11 More recently, the World Health Organization (WHO) introduced the term “eHealth” to include a wider range of remote services such as “health surveillance, health literature, and health education, knowledge, and research” that are provided through telehealth/telemedicine.¹²

The term “telepractice” was adopted by the American Speech-Language-Hearing Association (ASHA) and included practice sites such as schools, community centers, child care centers, and corporate settings, where telepractice may be implemented.¹³ The utilization of telepractice to deliver audiological services is commonly accepted today as “teleaudiology.” As evident from the evolution of terms from telemedicine to teleaudiology, remote delivery of audiology services will likely evolve as the field adapts to new technologies and audiology practice growth.

How Is eAudiology Defined?

Definitions of “tele-” services have largely focused on the setting or the medium through which care is provided. However, these definitions have placed less focus on a component that is critical to the success of this type of practice—the patient. The scope of teleaudiology is often limited to remote diagnostic evaluations or remote hearing aid fittings—not realizing the broader application of teleaudiology along the entire patient journey.

In order to reinforce the roles of the Internet and mobile computing in remote care, the consensus group recommends adoption of the term “eAudiology” to encompass technologies and services that enable remote provision of audiologic care at each stage along the patient journey, including screening, assessment, coaching, adjustments, monitoring, assistance, rehabilitation, and aftercare (Figure 2). It is important to keep in mind that eAudiology is an evolving field that is not necessarily replacing existing audiology practice. Rather, it is a timely growth of “teleaudiology” that takes into account the innovations currently in development that offer a wider scope of remote audiologic services.

What Are the Barriers to Clinical Adoption of eAudiology?

For the practice considering adoption of eAudiology services, the process is likely to be both exciting and challenging. Professionals may have feelings of uncertainty with how to navigate this new approach to delivery within their day-to-day services. Patients may initially experience a lack of confidence in how to access services remotely.

Fear of technology and fear of disrupting our personal connection are barriers that both clinicians and patients commonly express. Such obstacles, in our view, are addressed when care is provided from a Family-Centered Care (FCC) perspective; that is, when care is respectful and responsive to individual patient preferences, needs, and values.¹⁴

In other words, eAudiology services will not be appropriate for all patients, nor will they replace live interactions. Instead, clinicians and patients should both be involved in determining who could benefit from eAudiology on a case-by-case basis according to the unique needs and circumstances of each patient.¹⁵ The main consideration related to technology should be how it can be effectively used as one of many tools that can help increase patient reach and enhance patient care.

How Can eAudiology Benefit Patients? 

A growing body of evidence has demonstrated that eAudiology services deliver significant value for patients by helping them overcome challenges of distance and access to care.¹⁵ However, for today’s patient population for whom technology is rooted in everyday life, eAudiology may be a preferred style of connecting to and receiving service rather than a necessity.¹⁶

In a recent study evaluating the benefits of remote audiologic follow-up care, 82% of patients surveyed were able to install software with no assistance, and 60% stated that they would prefer remote appointments in the future over face-to-face appointments.¹⁷ Seemingly, the convenience and autonomy that eAudiology solutions offer can accommodate busy lifestyles and potentially improve patient outcomes by removing barriers to care, such as time, distance, and health/mobility.¹⁵

In addition, eAudiology offers more opportunities for FCC, an approach in which the needs of patients and family members are valued and where all parties play a central role in clinical decision-making along with the hearing care provider.¹⁵ Research suggests that both patients and family members prefer family-centered approaches when it comes to audiologic care.¹⁸ By utilizing solutions that offer remote support, family members who are separated geographically or are unable to attend face-to-face appointments can still be involved in the care of their loved ones.

How Can eAudiology Benefit Hearing Care Providers?

Beyond the potential benefits to patients, eAudiology offers an opportunity for clinicians to re-evaluate traditional service models and integrate new patient-centric technology solutions within their practice. By using eAudiology services, clinicians can offer patients cost-effective options and amenities that can improve quality of care, provide greater access, and increase the cumulative value of the clinician’s services. New services create additional avenues for clinicians to educate and guide patients. This, in turn, may increase customer loyalty as patients realize that clinicians are invested in providing the best care, and are proactive in finding the right solutions for their individual needs. Other benefits of eAudiology to the clinician include increased workflow efficiency and greater flexibility that allow for a better work/life balance.

How Can eAudiology Benefit Business Practice?

With the increased availability of offerings such as over-the-counter (OTC) products, Internet sales, and hearable devices (and the limited professional care that is expected to come with them), eAudiology services provide an opportunity to differentiate oneself from competitive threats. By offering innovative, patient-centered care options that patients are not receiving from these newer offerings, audiology practices can elevate value for patients.

Moreover, remote solutions allow for added convenience and expanded patient reach to larger geographical areas without the burden of physically adding space or changing the location of a practice. eAudiology solutions also enable evaluation of hearing instruments and experiences of patients in their everyday listening environments rather than artificial conditions when evaluations take place in the clinic. Thus, eAudiology may help retain existing patients, attract new patients, and provide enhanced care.

One of the potential benefits of eAudiology to a business practice is an associated cost savings. Compared to traditional service delivery, eAudiology solutions have the potential to reduce costs through increased efficiency in patient management, improved workflow through shared roles and responsibilities of clinic staff, and improved patient satisfaction.¹⁹

Steps toward eAudiology Implementation

Although clinicians may realize that eAudiology services provide a significant opportunity to optimize clinical practice, the thought of implementation may seem overwhelming due to various factors. We have identified several key factors that clinicians should consider as they plan to incorporate eAudiology services within their practice.

• Patient candidacy.Determine if a patient is a candidate for services delivered by eAudiology prior to initiating services. eAudiology is not appropriate for or desired by all patients, and thus candidature should be taken into account. Certain factors, such as age, lifestyle, education, experience with technology, and family involvement, can potentially inform a patient’s appropriateness for eAudiology services.¹³
• Clinician education and training. The provision of audiological care via eAudiology requires a behavior change from hearing care professionals. Such changes range from assessing which clinical tasks are appropriate for eAudiology, to recognizing that communication behaviors will be different. For example, remote support may change how we perceive non-verbal communication, and we may be unable to fully observe facial and body language. It is important to ensure clinicians and support personnel are adequately trained and ready to incorporate eAudiology services within their workflow. It is very likely the case that important lessons will take place as hearing care professionals trial eAudiology practice.²⁰
• Technology infrastructure. Assess your technology infrastructure to determine what equipment and wireless services are needed for seamless delivery of remote audiologic care.^19,20 For example, is your clinic located in a region with adequate Internet bandwidth to accommodate eAudiology service, and do patients have the necessary home-based technology?
• Regulatory environment. Importantly, the regulatory environment governing clinical practice is actively evolving. Be knowledgeable of the regulatory laws relevant to eAudiology services, including Health Insurance Portability and Accountability Act (HIPAA), reimbursement and credentialing/licensing requirements, especially across national and international borders.^19,20

Conclusion

Advances in mobile technologies, computing, and communication, the development of OTC and alternative hearing care products, and changes in patient attitudes toward assuming a greater role in their own healthcare all suggest a profound shift from traditional service delivery. eAudiology offers exciting and creative options that can enhance the value of professional hearing services through the use of technology solutions rooted in personalized and tailored family-centered care.

Biographies: Joseph Montano, EdD, is a Professor of Audiology and Director of Hearing and Speech at Weill Cornell Medical College, New York Presbyterian Hospital; Gina Angley, AuD, is the Associate Director of Adult Amplification at the Vanderbilt Bill Wilkerson Center in Nashville, Tenn; Colleen Ryan-Bane, MS, is an audiologist and Assistant of Otolaryngology-Head and Neck Surgery at Johns Hopkins, Baltimore, Md; William Campbell, MClSc, is an audiologist and owner of Superior Hearing Centre in Thunder Bay, Ontario, Canada; Robert Eikelboom, PhD, is Senior Scientist at the Ear Science Institute Australia in Perth; Andrea Gerlach, AuD, is Executive Director at the Dallas Ear Institute; Danielle Glista, PhD, is an Adjunct Research Professor at the National Centre for Audiology at Western University in London, Ontario; Karen Muñoz, EdD, is a Professor of Audiology at Utah State University; Christine Jones, AuD, is Director of the Phonak Audiology Research Center (PARC) in Warrenville, Ill; Melanie Ferguson, PhD, is a Consultant Clinical Scientist in Audiology and Associate Professor in Hearing Sciences at the NIHR Nottingham Biomedical Research Centre, United Kingdom; De Wet Swanepoel, PhD, is Professor of Audiology at the University of Pretoria in South Africa; Ora Buerkli-Halevy, MS, is VP of Global Audiology at Phonak AG; Gurjit Singh, PhD, is a Senior Research Audiologist at Phonak AG, Adjunct Professor at Ryerson University, and Adjunct Lecturer at the University of Toronto; Davina Omisore, MSc, is a Marketing Audiologist at Phonak AG; Martina Schuepbach-Wolf, BSc, is a hearing aid specialist at GEERS Hörakustik in Wittlich, Germany; and Francois Julita, MS, MBE, is Director of Digital Transformation at the Sonova Group, Stäfa, Switzerland.

Correspondence can be addressed to Dr Montano at: [email protected]

Original citation for this article: Montano J, Angley G, Ryan-Bane C, et al. eAudiology: Shifting from theory to practice. Hearing Review. 2018;25(9):20-24.

References 

1. Roga A. Telehealth adoption to double by 2018. Hospitals & Health Networks website. https://www.hhnmag.com/articles/8350-telehealth-adoption-to-double-by-2018. June 12, 2017.

2. Topol E. The patient will see you now: The future of medicine is in your hands. New York, NY:Basic Books;2016.

3. Maslansky M. The language of trust: Selling ideas in a world of skeptics. Upper Saddle River, NJ:Prentice Hall Press;2011.

4. S.670–Over-the-Counter Hearing Aid Act of 2017. GovTrack website. https://www.govtrack.us/congress/bills/115/s670. Updated March 1, 2017. Accessed February 8, 2018.

5. Kahana E, Kahana B. Baby Boomers’ expectations of health and medicine . AMA Jour Ethics.2014;16(5):380-384.

6. Wilson LB, Simson SP, eds. Civic engagement and the baby boomer generation: Research, policy, and practice perspectives. Abingdon, United Kingdom:Routledge;2006.

7. Anderson M, Perrin A, Pew Research Center. Tech adoption climbs among older adults.http://www.pewinternet.org/2017/05/17/tech-adoption-climbs-among-older-adults/pi_2017-05-17_older-americans-tech_1-03/. Published May 17, 2017.

8. State of the smart: Consumer and business usage patterns:Global mobile consumer survey 2017: UK cut, Deloitte.  https://www.deloitte.co.uk/mobileuk/assets/img/download/global-mobile-consumer-survey-2017_uk-cut.pdf.

9. Eikelboom RH, Swanepoel DW. International survey of audiologists’ attitudes toward telehealth. Am J Audiol.2016; 25(3S): 295-298.

10. About telemedicine. American Telemedicine Association(ATA) website. http://www.americantelemed.org/main/about/about-telemedicine

11. World Health Organization (WHO). Telemedicine: Opportunities and developments in member states: Report on the second global survey on eHealth. http://www.who.int/goe/publications/goe_telemedicine_2010.pdf. 2010.

12. eHealth. World Health Organization (WHO) website. http://www.emro.who.int/health-topics/ehealth/.

13. Telepractice. (Practice Portal). American Speech-Language-Hearing Association  (ASHA) website. http://www.asha.org/Practice-Portal/Professional-Issues/Telepractice

14. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century.Washington, DC:The National Academies Press;2001.

15. Swanepoel DW, Hall JW III. A systematic review of telehealth applications in audiology. Telemedicine and e-Health.2010;16(2):181-200.

16. Carr G. Using telehealth to engage teenagers. ENT and Audiology News. 2017; 25(6).

17. Angley GP, Schnittker JA, Tharpe AM. Remote hearing aid support: The next frontier. J Am Acad Audiol. 2017;28(10):893-900.

18. Singh G, Hickson L, English K, et al. Family-centered adult audiologic care: A Phonak position statement. Hearing Review. 2016;23(4):16-20.

19. Ballachanda B. Critical steps in establishing a teleaudiology practice. Hearing Review.2017;24(1):14-17.

20. Krupinski EA. Innovations and possibilities in connected health. J Am Acad Audiol. 2015;26(9):761-767.