Tele-audiology will extend the care and DAEs provided by pediatric audiologists to remote regions while retaining quality of service standards
Conducting infant diagnostic audiological evaluations (DAE) over the Internet is one of the most promising applications for tele-audiology. Four factors support developing a tele-audiology infant DAE clinical practice:
- Shortage of pediatric audiologists. There is a critical shortage of pediatric audiologists worldwide. In the United States, this shortage has been noted since the widespread inception of universal newborn hearing screening programs.1 In a survey of all 50 states, the District of Columbia, and eight US territories, nearly half of universal newborn hearing screening programs cited a lack of a pediatric audiologist as a major obstacle to diagnostic evaluation.2 Early hearing detection and intervention (EHDI) programs recommend that infants receive hearing screening by 1 month of age, diagnostic evaluation by 3 months of age, and enrollment in early intervention by 6 months of age (ie, the “1-3-6 goal”). If diagnostic audiological evaluation is not readily available, communities cannot achieve this goal. Using tele-audiology to extend the expertise of pediatric audiologists to underserved communities could improve follow-up for infants who refer on newborn hearing screening and help communities achieve the 1-3-6 goal.
- Testing equipment. The diagnostic equipment needed to conduct infant DAEs is largely PC based. Using remote control software, audiologists can operate the diagnostic equipment located at a distance site from their desktop PC. High-speed, broadband Internet connectivity makes data streaming from the diagnostic equipment to the audiologist’s desktop almost instantaneous.
- Videoconferencing. For real-time tele-audiology applications, videoconferencing is needed for communication between the audiologist, the patient or family, and the support personnel at the patient site. Newer laptops and tablets typically come with a microphone and videocamera(s) as a standard option. For older computer technology, inexpensive USB videocamera/microphone combinations are available. Low- and even no-cost videoconferencing software is also available, including some with well-defined encryption methodologies to protect privacy. The expansion of 4G telecommunication networks, allowing mobile ultra-broadband Internet access to laptops with USB wireless modems, smartphones, and other mobile devices, may expand the reach of tele-audiology services well beyond hospital, university, or clinic settings.
- Guidelines. Finally, guidance in development of a tele-audiology practice is readily available. Both the American Academy of Audiology and the American Speech-Language-Hearing Association have developed informative documents on tele-practice outlining professional issues and knowledge and skills needed for this method of service delivery. In addition, the American Telemedicine Association provides substantial information on development of telehealth in general. Using these documents, most universities, hospitals, and clinics can readily develop a program of tele-audiology.
A Pilot Project
To test the concept of tele-audiology for infant DAEs, Children’s Hospital Colorado developed a pilot project with the Early Hearing Detection and Intervention (EHDI) program in Guam, a US island territory in the western Pacific. We chose to collaborate with Guam EHDI because the island has a successful newborn hearing screening program for civilian infants born on the island, but lacks an audiologist with experience in infant DAE.
Guam EHDI purchased PC-based diagnostic audiological equipment needed for infant DAEs. Children’s Colorado audiologists control this equipment from their desktop computers in Colorado using remote control software. A laptop at each site is used for videoconferencing. Guam EHDI has access to encrypted videoconferencing software; Children’s Colorado audiologists join the videoconference by connecting to Guam’s secure host URL.
Because professional licensure is required at the site of the patient regardless of the site of the practitioner, Children’s Colorado audiologists obtained professional licensure in Guam. Infant DAEs require significant “hands on” preparation of the baby for testing. For this project, audiometrists from the Guam Department of Education prepare the infant for testing. These support personnel were trained by the audiologists for their role in tele-audiology infant DAEs. The audiometrists conduct otoscopy and tympanometry, and apply/remove electrodes, place earphones and bone vibrators, calm the infant, and support the family.
The test protocol for tele-audiology infant DAEs complies with Joint Committee on Infant Hearing3 recommendations and consists of otoscopy (as reported by the audiometrist), tympanometry, auditory evoked potential measures (ABR and ASSR), and OAEs. Results are obtained on each ear by air-conduction and, if needed, bone conduction. Masking is employed when necessary to obtain ear-specific measures. Auditory evoked potential thresholds at audiometric frequencies from 500 to 4000 Hz are obtained in both ears, allowing us to estimate the infant’s pure-tone audiogram.
Families whose infants refer on the Guam two-stage newborn hearing screening are offered a tele-audiology infant DAE within 2 to 3 months of birth. Infants identified as deaf or hard-of-hearing are referred to appropriate on-island providers for medical/otologic assessment, hearing aids if needed, and early intervention services.
Eight infants have been tested by tele-audiology using the test and follow-up protocols described above. No technical or environmental issues have interfered with tele-audiology or prevented satisfactory completion of the test battery for these infants. Minor technical problems, such as dropped Internet connectivity and videoconferencing failures were resolved promptly on the few occasions when these occurred.
DiscussionQuality of service is arguably the most important consideration in a successful tele-audiology practice. Services delivered over the Internet should be equivalent to services delivered face-to-face. Three crucial elements that impact tele-audiology quality are:
- Utilizing appropriate technology for the services offered;
- Employing acceptable test protocols; and
- Ensuring a suitable test environment.
The Guam EHDI Program invested in state-of-the art diagnostic audiometric equipment appropriate for infant DAEs. Using remote control software, Children’s Colorado audiologists operate this equipment, monitoring the test procedure in progress, and reviewing the test result. Data streaming from Guam to Colorado is fast enough to allow the audiologist to pause data acquisition if movement or other artifact contaminates the data.
The cost of diagnostic audiological equipment suitable for infant DAEs may be a barrier for tele-audiology practice in some communities. To overcome this barrier, one tele-audiology practice serving a network of communities reports shipping the diagnostic equipment to the network site prior to an evaluation. The support personnel at the network site are responsible for assembling and testing the equipment prior to the infant DAE.4
The diagnostic protocol for infant DAE delivered by tele-audiology is the same as that used at Children’s Colorado for in-person services and complies with Joint Committee on Infant Hearing3 recommendations for infant DAE. The protocol allows the audiologist to estimate degree and frequency-specific configuration of the infant’s audiogram by air- and bone-conduction in each ear, and evaluate middle ear, cochlear, and neural auditory function.
The test environment for infant DAEs must meet acceptable standards for comfort, safety, and privacy and confidentiality. The environment selected by the Guam EHDI program is a house on the University of Guam campus (previous faculty housing) used exclusively for infant DAEs. It is private, quiet, and outfitted appropriately for family comfort. This test environment supports videoconferencing and minimizes ambient noise that could disturb the infant and family.
Two quality-of-service issues have emerged through this project. First, because video otoscopy is not employed, the audiologists rely on the audiometrists to conduct the otoscopic assessment and verbally report their findings. The audiometrists routinely conduct otoscopy on older children (ages 3 years and older) but have minimal experience with infants. Given the challenges of otoscopy on very young infants, the eardrum may not be visualized and the assessment may be limited to looking for occlusion of the ear canal. Financial limitations preclude purchase of video otoscopy equipment for this project; however, we would recommend video otoscopy for programs considering a tele-audiology infant DAE program.
Second, family counseling by videoconferencing is less optimum than face-to-face counseling. Ability to gauge parents’ reactions to information is imperfect, and opportunity for follow-up interaction is limited. Furthermore, Children’s Colorado audiologists have no practical experience with follow-up services on Guam. To address this issue, we have encouraged that, with the family’s permission, family support personnel from Guam Early Intervention Services are present during testing and counseling to support the family and facilitate follow-up services.
Our pilot project demonstrates that tele-audiology for infant DAEs can be accomplished using hardware and software applications readily available on the commercial market. For infants and their families in Guam, tele-audiology makes the EHDI goal of diagnosis by age 3 months feasible. Other practices serving remote and distant locations report similar success in reducing time to diagnosis through tele-audiology.4 In the end, family acceptance of this model of service delivery will determine tele-audiology’s role in EHDI programs.
This project was supported in part by a grant from Daniels Fund to Children’s Hospital Colorado to establish Bill Daniels Center for Children’s Hearing. Significant support for this project has been provided by Sue Dreith, Ericka Schicke, and Bereket Habte in Colorado, and Elaine Eclavea, Vickie Ritter, David Zeiber, Bobbie Maguadog, Laurie Soto, Ron Nochefranca, J. J. Mendiola, and Sean Lizama on Guam.
CORRESPONDENCE can be addressed to:
- Nemes J. Success of infant screening creates urgent need for better follow-up. Hear Jour. 2006;59:21-28.
- Shulman S, Besculides M, Saltzman A, Ireys H, White KR, Forsman I. Evaluation of the universal newborn hearing screening and intervention program. Pediatrics. 2010;126:S19–S27.
- Joint Committee on Infant Hearing (JCIH). Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(40):898-921.
- Campbell W, Hyde M. eEHDI: Functions and challenges. Proceedings from A Sound Foundation Through Early Amplification International Pediatric Audiology Conference; Chicago; November 8-10, 2010. Available at: www.phonakpro.com.
ALSO IN THIS SPECIAL ISSUE (OCTOBER 2012) ON TELEAUDIOLOGY:
- Extending Hearing Healthcare: Tele-audiology, by Jerry Northern, PhD
- The Need for Tele-audiometry, by De Wet Swanepoel, PhD
- Are You Ready for Remote Hearing Aid Programming? By Jason Galster, PhD, and Harvey Abrams, PhD
- Infant Diagnostic Evaluations Using Tele-audiology, by Deborah Hayes, PhD
- Online Global Education and Training, by Richard E. Gans, PhD
- Therapeutic Patient Education via Tele-audiology: Brazilian Experiences, Deborah Viviane Ferrari, PhD
- Telepractice in the Department of Veterans Affairs, by Kyle C. Dennis, PhD, Chad F. Gladden, AuD, and Colleen M. Noe, PhD