Practice Management | January 2017 Hearing Review
Part 1: A 10-point checklist when planning for a teleaudiology program
Interested in building a teleaudiology program into your existing hearing care practice or organization? Here is some practical advice, as well as 10 items to consider in your planning.
Telehealth is the delivery of health-related services and information via telecommunications technologies. Telehealth can be as simple as two healthcare professionals discussing a case over the telephone, or as sophisticated as doing robotic surgery between facilities at different ends of the globe. Increasingly, telehealth is encompassing real-time patient evaluations using internet access via video and audio interfaces.
Teleaudiology is the utilization of telehealth to provide audiological services. Northern1 defined teleaudiology as “electronic information and telecommunications technologies to support remote and distance clinical hearing healthcare, professional and public education, public health matters, and health administration.” This type of extended care has been effectively used in many countries, as well as by several organizations in the United States.2-6
The Challenge and Opportunity of Telepractice in Hearing Healthcare
The global challenge and opportunity for hearing care in the coming years is enormous. As a profession, we are faced with three critical issues that make the provision of hearing services in the future challenging:
1) Global economy and recognition of the value of hearing healthcare. Recent shifts in the global economy have created in many countries an awareness and affordability for audiologic services. In the past, audiologic services did not command the same attention as other health-related issues; however, countries with emerging markets and a greater economic independence have changed their perceptions of audiology and are recognizing the importance of better hearing, early intervention, and overall attention to the hearing-impaired population. The global awareness of audiology services has created a greater demand; stated differently, there is considerable demand for audiological services in various parts of the world.2,7
2) The graying of America. A large segment of the US population is quickly approaching its senior years, which guarantees that our obligations and responsibilities to provide hearing services to older people will command our attention and stress our system for more services.8 Americans aged 65 and older are expected to nearly double by the middle of the century, and will make up more than a fifth of the nation’s population, according to the US Census Bureau.
3) Shortage of audiologists and other skilled hearing care professionals. There is a shortage of hearing care providers in the United States to meet these future needs. Multiple studies show successful hearing aid fittings depend on skilled hearing care professionals and their expertise. Yet, research by Freeman9 has shown little or no real growth in the number of audiologists being trained in university programs. The number of new audiology professionals entering our field each year is neutralized by the nearly equal numbers of senior audiologists reaching and seeking retirement.
With increased awareness of these opportunities, we can immediately adopt teleaudiology services in our daily work. In my view, it is of paramount importance that we, as hearing healthcare providers, find creative and cost-effective ways to deliver hearing care if we are to survive and thrive as a profession. Teleaudiology, in its most fundamental application, allows for virtual communication, using real-time audiovisual information transmitted between a patient and a hearing care provider, each located at a different site. Use of this technology—and its expansion to all facets of the audiological process—has the potential to dramatically reduce the cost and increase the efficiency of providing hearing care. By implementing new ways patients are being evaluated and managed, from the traditional methods of in-person care to remote care, we will be able to resolve many of the future challenges in service delivery.
Benefits of Teleaudiology
The American Medical Association (AMA) has not only promoted the use of telemedicine, but it is also advocating for the formalized training of physicians in telemedicine.10 This is because the benefits of teleaudiology are so numerous. Although there are few studies related to the benefits of teleaudiology, per se, numerous studies from telemedicine have identified at least four fundamental benefits:
Improved access. Although the obvious focus is to improve access for patients, teleaudiology also allows audiologists, other hearing care providers, and hearing clinics to expand their reach beyond their offices and clinics. Given the provider shortages throughout the world—in both rural and urban areas—teleaudiology has a unique capability to increase service to millions of patients who otherwise might not receive quality hearing care.
Cost efficiencies. Reducing or containing the cost of hearing care is one of the most important reasons for funding and adopting teleaudiology technologies. Teleaudiology has been shown to reduce the cost of hearing care and increase efficiency through better management of patients, shared clinic staffs, reduced travel times/expenses, and fewer cases of patient dissatisfaction.
Improved quality. Studies have shown that the quality of healthcare services delivered via telemedicine are as good as those given in traditional in-person consultations. In some specialties—particularly in mental health and ICU care—telemedicine delivers a superior service, with better outcomes and patient satisfaction. Similarly, one can expect teleaudiology to provide improved hearing care for many patients.
Patient demand. At present, we have not achieved the status of patients demanding teleaudiology as a substitute for in-person care. However, consumers want telemedicine, and the greatest impact of telemedicine is on the patient, their family, and their community. Using telemedicine technologies reduces travel time and related stress for patients—many of whom have mobility issues. Efficiencies can also be realized for patients who can be seen for relatively quick/routine tasks.
Teleaudiology Delivery Mechanisms
The teleaudiology delivery model is generally following telemedicine concepts. In order to understand the extent to which teleaudiology can be used, it may be helpful to briefly outline how telehealth has been implemented in patient care.
Networked programs link tertiary care hospitals and clinics to outlying clinics and community health centers, often in rural or suburban areas. The links may use dedicated high-speed lines or the Internet for telecommunication links between sites. The American Telemedicine Association (ATA) estimates the number of existing telemedicine networks in the United States at roughly 200, providing connectivity to about 3,500 sites.11
Point-to-point connections using private high-speed networks are used by hospitals and clinics that deliver services directly or outsource specialty services to independent medical service providers. Such outsourced services include radiology, stroke assessment, mental health, and intensive care services.
Monitoring center links are used for cardiac, pulmonary, or fetal monitoring, home care, and related services that provide services to patients in the home. Often, normal landline or wireless connections are used to communicate directly between the patient and the center, although some systems use the Internet.
Web-based e-health patient service sites provide direct consumer outreach and services over the Internet. Under telemedicine, these include sites that provide direct patient care.
It is not difficult to see how each of these delivery mechanisms could be applied in teleaudiology and provide the same level of services that telehealth has provided for years.
Teleaudiology & Remote Hearing Services
Teleaudiology and remote hearing care services don’t necessarily have to entail a complex program; they can range from counseling to hearing screening to full-blown clinical diagnostics and service. A comprehensive teleaudiology clinic can provide:
1) Video otoscopy;
2) Hearing screening;
3) Diagnostic testing, hearing evaluation, tympanometry, auditory brainstem testing, OAE testing, etc;
4) Hearing aid fitting, programming, orientation, and verification and validation of the hearing aid fitting;
5) Counseling and AR programs;
6) Trouble-shooting hearing aids, and
7) Tinnitus evaluation and management.
Guide to Building a Successful Teleaudiology Program
Any teleaudiology program will evolve from its inception, and many lessons can be learned along the way. These lessons become “best practices” for new programs, and guide the development and/or expansion of teleaudiology. Getting started and implementing structure to your program helps it get “online” more quickly and operate more efficiently. The following checklist is a culmination of learning from other audiologists and industry experts, the author’s experiences, as well as from other disciplines in healthcare. Specifically, the guide was developed from prior experience in hosting a teleaudiology program in the United States, with future implementation of it in Kenya, Tanzania, India, and other countries.
1) Assess and confirm your readiness to start a teleaudiology program.
There’s no sugar-coating the required work and capital that goes into establishing an efficient teleaudiology program; it is costly, time-consuming, and challenging to start, even if it may sound and look easy. It is important to perform a formal assessment of readiness by examining the advantages and potential problems before starting the program. Any teleaudiology program should:
- Match the mission/vision and goals of the organization, clinic, or practice;
- Align itself with a full SWOT analysis (Strengths, Weaknesses, Opportunities and Threats) of the clinic or the organization to help justify the need for a teleaudiology component;
- Identify and recruit appropriate people to start this program;
- A needs analysis will help identify key unmet needs and help devise effective strategies and approaches to meet them. It will provide a sound foundation for planning, clarifying objectives and shared expectations, implementing coordination of services, and improving the financial status of the clinic.
- Identifying the equipment needed should not be your highest priority; this should be a component of the pre-planning phase.
You and your staff should develop a clear understanding of the mission and the types of services your teleaudiology program will deliver. Importantly, this includes the level(s) of service (eg, basic hearing screening versus comprehensive audiology services). You must also factor in geographical location/regions (distance from the main center), and the financial commitment to start the program.
2) Perform a market analysis and write a business plan.
A market analysis will help determine demand for the proposed services. A business plan will help identify resources, allocation of funds, and approval from the appropriate personnel:
- Is there a clear need for and a significant demand for the services provided in that geographic area? It is also wise to remember that there can be great need for a particular service in an area, but not necessarily the demand and/or purchasing power to pay for that service.
- Focus beyond the “here and now.” Don’t base your plan on speculation.
- Identify and develop revenue opportunities and fiscal estimates.
- Reimbursement/payment is one of the most challenging items in implementing a sustainable teleaudiology program. In the long run, programs require reliable, adequate revenue and reimbursement for clinical services.
- The plan must include detailed information on timelines, deliverables and milestones, technical requirements, and potential challenges.
Create a detailed programmatic and technical implementation plan. The most successful teleaudiology programs are the result of careful, detailed planning and the deployment of well-considered integrated and streamlined technologies.
3) Build a team trained to forge ahead.
Any program stands and falls by the people implementing it. In the case of teleaudiology, identifying and/or hiring the right staff at both the satellite (remote) and the control site—and clearly defining their roles and responsibilities—is crucial. Whenever possible, dedicated staff should be hired who fully understand the program’s outreach goals and ambitions. The provision of effective ongoing training and personnel development is immeasurably important. Actively nurture them.
- Identify a coordinator to oversee all daily operational activities of the program, including scheduling, billing, technical operations, etc.
- Make sure all staff are technically savvy and knowledgeable about the teleaudiology program, and applications. All staff should be flexible, “onboard,” and willing to adapt to these new clinical methods and approaches.
- Create an environment in which staff at both sites can work well together to create a seamless, comfortable, and reassuring clinical atmosphere for the patients.
- Develop and implement a formal, comprehensive, and standardized training regimen for all staff. Training must be ongoing and will inevitably increase in scope and scale as the teleaudiology program expands.
4) Purchase the right equipment.
Identify and select the right equipment for teleaudiology application and delivery mode. Video equipment, communication systems (high-speed internet connection), test equipment, and software programs/applications are critical components of a successful program. Seek and obtain information and advice related to various equipment, and learn the functionality, features, and interoperability of the various teleaudiology devices.
- Clearly identify appropriate specifications for the devices, applications, and all communication systems.
- Identify trustworthy and knowledgeable sources to learn about equipment choices, and the ongoing support provided to start and sustain a teleaudiology program.
- Be mindful that technology advances quickly, and systems and applications will need upgrading and warranty renewals. There can be substantial costs involved, and this should be noted in the budget.
- Test, test, and test again! Be certain about the equipment and connectivity before announcing or advertising the availability of your teleaudiology program.
5) Create an effective and professional environment that can emulate a traditional face-to-face encounter.
The environment at both clinic and satellite locations should be professional, and should be able to closely emulate a face-to-face interaction. It should be user friendly, well-equipped with reliable and appropriate technology, and comfortable for patients and staff. Both locations should be designed for effective videoconferencing:
Follow basic and standard rules for the design of both the similar to face to face interaction. When designing teleaudiology room space, pay close attention to room location, size, equipment, furniture placement, lighting, acoustics (must be as quiet as possible), patient privacy, and wall color (for video background).
- Plan carefully and discuss the design with program colleagues and IT personnel.
- Remember to include necessary design/remodeling costs into the budget.
- Make sure the design follows the building codes and any other requirements.
6) Plan for the seamless integration of teleaudiology between sites.
Teleaudiology activities should be designed to complement standard practices and working methods, not complicate or interrupt them. Teleaudiology should be integrated alongside face-to face-clinical activities. To accomplish this, plan a workflow analysis to reveal how your program fits in with standard clinical practice. Discuss necessary changes with the members of your team.
- Think of the teleaudiology technology as just another tool for the delivery of normal services, with the only difference being that the patient isn’t in the same room as the provider.
- Keep it simple.
7) Plan for the availability of IT support at all participating locations.
Having ready access to trained and knowledgeable IT personnel and network support staff is critical to the effective running of a teleaudiology program. During consults or any clinical interaction taking place via the teleaudiology system, trained and efficient technical staff must be on hand to troubleshoot and make technical adjustments as necessary. Both equipment and network expertise is essential, and staff must have appropriate authorizations to make network changes, as needed. It is vital that an IT person is identified and that the IT department is involved to provide authorization and approval of technical plans and strategies.
- Focus on introducing IT personnel at all sites to each other. The better they know each other, the smoother they’ll be able to troubleshoot a problem.
- Educate IT personnel about teleaudiology needs and technologies, and authorize them to work directly with network systems and settings.
- Familiarize all IT staff in your organization (either working directly with your program or not) with all the systems, applications, and network needs. There can be wider IT system dependencies and knock-on effects of teleaudiology operations that may not be apparent until it is too late.
8) Establish protocols, policies, and procedures, as well as short- and long-term performance goals.
Written clinical and service protocols should be available to all personnel involved in the telaudiology program, similar to the one used for face-to-face interactions.
- Create protocols that are as close as possible to face-to-face interaction. This will instill far greater comfort and confidence in the clinicians—professionals who should not feel that they are doing something strange, unusual, or way out of line with their traditional practices.
- Follow standard recognizable protocols which lead to consistent clinical results that are vital for the evaluations and program monitoring.
- Establish longer-term goals that consider clinical, business, and financial outcomes several years into the future and movement towards programmatic self-sustainability.
9) Develop an evaluation, monitoring, and quality-improvement plan.
Implement an evaluation process to review the program and monitor its performance on a regular basis. Build systems into the program to measure and analyze program performance. In the planning stage, determine assessment methods, evaluation strategies, and build a plan to create routine performance monitoring. You may even consider the need for formal evaluation of clinical services and operational or cost impacts.
Identify what should be monitored, how frequently, and by what methods. Evaluation and monitoring should be shared and agreed with all participants.
- Monitor and evaluate all key elements of the program on a regular and ongoing basis.
- Include a range of topics in the evaluation plan, including service usage, patient and provider comfort level with particular technologies, devices and applications, and cost savings analysis.
- Be sure to monitor and track ancillary or related services benefiting from teleaudiology program and activities.
- Evaluate the strengths and weaknesses (eg, SWOT) of the program on a regular basis.
- Implement new ideas, adjustments and solutions in an organized fashion.
- Constant quality improvement must be a part of regular operations.
10) Understand the legal and regulatory issues of teleaudiology.
There are a wide range of legal and regulatory issues and requirements that must be understood and complied with when developing a teleaudiology program. Regulations and laws can change periodically and must be implemented as required.
- Identify the current policies and regulations, and determine the impact they may have on a teleaudiology program. Critical legal and regulatory areas to consider include licensure, credentialing, and HIPAA.
- Consult with legal counsel to ensure that the program follows laws and regulations and implement any new requirements.
In summary, building a successful teleaudiology program includes the following:
- Support from your clinical staff and leadership;
- Identifying the challenges and opportunities of teleaudiology;
- Partnering with industry, clinical, technical, and administrative staff;
- Developing protocols, toolkits, and best practices;
- Being flexible and having staff “buy-in”;
- Carefully evaluating service delivery and outcomes, and
- Providing education and training on an ongoing basis to members of the team.
A follow-up article by the author and Jim Armstrong about how to implement teleaudiology in a dispensing practice will appear in a future edition of The Hearing Review.
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Correspondence can be addressed to HR or Dr Ballachanda at: firstname.lastname@example.org
Original citation for this article: Ballachanda B. Critical Steps in Establishing a Teleaudiology Practice. Hearing Review. 2017;24(1):14.