A Pilot Investigation Into the Provision of Hearing Services Using Tele-Audiology to Remote Areas

A Pilot Investigation Into the Provision of Hearing Services Using Tele-Audiology to Remote Areas
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  96 THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF AUDIOLOGY VOLUME 31 NUMBER 2 NOVEMBER 2009pp. 96–100 A pilot investigation has been conducted byAustralian Hearing to assess the feasibility of provid-ing hearing services using tele-audiology to adultclients in remote areas. The services on trial includedhearing assessment, hearing aid fitting,and hearingrehabilitation. The equipment used for remote areaservices, the personnel required, and the methodologyused are outlined. Case studies are presented andimplications for future needs discussed. Keywords: tele-audiology, remote areas Australian Hearing is an Australian Govern -ment agency that provides a full range of hearing services across the country — includ-ing service to remote areas — for childrenand young people up to the age of 21, agedpensioners, and war veterans across thecountry. The provision of specialist healthservices to people who are located at adistance from a service centre is costly; it isalso limited by difficulties in transportingequipment, and susceptibility to the adverseeffects of extreme weather on access by roador air.With advancements in technology andtelecommunication networks, it has becomepossible for audiological equipment to beremotely controlled by personal computersusing custom-designed software. Trials of these ‘tele-audiology’ methods have beenconducted for hearing assessment (Choi,Lee, Park, Oh, & Park, 2007; Krumm, 2007;Krumm, Huffman, Dick,& Klich, 2008) andhearing aid adjustment (Wesendahl, 2003).Krumm et al. (2008) reported that remotescreening of infants with otoacousticemissions and automated auditory brainstemresponses yielded similar results as thoseobtained on-site, when audiologists wereused at both ends of the screening trial.Wesendahl (2003) reported the viability of remotely fine-tuning a hearing aid by issuinga client with a hearing aid programmer andcommunicating with the client via telecon-ferencing facilities. The use of ‘store andforward’ technology has also been examined(Eikelboom, 2005; Polovoy, 2008). With thistechnology, high-quality video otoscopyobtained from a client located in a remoteregion could be transmitted to specialistsfor review and diagnosis. Despite the avail-ability of the technology, uptake of thesemethods for service provision in the UnitedStates has been slow, possibly due to thecosts of equipment and issues relating tolicensing and reimbursement (Krumm, ascited in Polovoy, 2008). In Australia,ear–nose– throat specialists demonstratedthat it was possible to provide consultation toremote areas using video- teleconferencingfacilities and ‘store and forward’ technology(Smith, Dowthwaite, Agnew,& Wooten,2008). They reported that clinical decisionsmade via this method were ‘confirmed for67 of the 68 patients after face-to-face A Pilot Investigation Into the Provision ofHearing Services Using Tele-Audiologyto Remote Areas WENDY PEARCE, TERESA Y.C.CHING AND HARVEY DILLON Australian Hearing, National Acoustic Laboratories, Australia Correspondence and reprint requests: Ms W. Pearce, Australian Hearing, Chatswood, NSW 2067, Australia. Brief Communications    Brief Communications   review by the same specialist (99% agree-ment)’ (p. 461).The vast expanse of Australiaand the needto provide equity of access to hearingservices for the populationhave expedited apilot investigation into the feasibility of usingtele-audiology methods for service provisionto adults in remote areas by AustralianHearing. Delivery of services via direct visitsto remote communities has resulted in longlengthy waiting periods and long inter-appointment intervals, resulting in reducedclient satisfaction. The aim of this investiga-tion was to explore the feasibility of an alter-native means of delivering services. The pilotstudy included performing hearing assess-ment and hearing aid fitting on at least fiveoccasions using tele-audiology. The trialswere carried out from the hearing centrescentrally located in Perth, Darwin, Cairns,Chatswood, Morwell and Warrnambool, tothe remote sites of Bairnsdale, FitzroyCrossing, Derby, Broome, Bamaga, Mareeba,Nhulunbuy and Wadeye. METHOD Equipment Australian Hearing has chosen specific,commercially available equipment that isrobust and portable. This includes a laptopcomputer; a small, computer-based audio -meter and real-ear measurement system; aloudspeaker; a hearing aid programming-interface unit; noise-excluding headphones; avideo otoscope; and a tympanometer. Thesehave a total weight of 7.2 kilograms. Personnel Hearing assistants located in remote commu-nities were trained to assist with fittingheadsets or real-ear measurement probes forlocal clients. Telecommunication A wireless broadband mobile card operating atup to 7.2 megabits per second was used fortransmission and reception. Video-conferenc-ing units (VCUs) were used for personalcommunication, and the Symantec softwarepcAnywhere (1995) was used to control the PROVISION OF HEARING SERVICES USING TELE-AUDIOLOGY 97 remote laptop computer and the audiologicalequipment. Procedure An audiologist based in a main city centrecommunicated with a hearing assistant and aclient located in a remote community. Tocarry out a hearing assessment, the audiolo-gist controlled a remotely situated audiometerusing her personal computer, and the hearingassistant connected the audiometer to thelaptop and placed headphones on the client asinstructed. The audiologist interviewed theclient via the VCU, viewed the ear using thevideo otoscopy and conducted the hearingassessment.For hearing aid fitting, the audiologistinstructed the hearing assistant to connect thehearing device and then controlled the hearingaid fitting software. The hearing assistantplaced the real-ear measurement probe in theear so that insertion gain measurement couldbe carried out to verify the fitting. With thehearing aid still connected, adjustments weremade according to the needs of the client.Discussions between the audiologist and theclient about amplification needs were carriedout via the VCU, both at the fitting appoint-ment and at the follow-up appointment. CASE RESULTS Case 1 A hearing assessment of Case 1 wascarriedout via tele-audiology and also at aseparateappointment attended in person. A compari-son of the hearing thresholds measured on thetwo occasions revealed a difference of nomore than +/– 5 dB at octave frequenciesbetween 0.5 kHz and 4 kHz. A discussion of amplification options was conducted byremote VCU and the client chose amplifica-tion with two behind-the-ear hearing aids. Anaudiologist in Nhulunbuy took ear impres-sions for making customised ear moulds forthe client. Case 2 Case 2 attended an appointment in a remotecommunity. A hearing assessment was carriedout using tele-audiology; it indicated that the  client had a large conductive hearing loss.Video otoscopy carried out remotely revealedthat the client had a large perforation in theeardrum. This image was sent electronicallyto an ear–nose–throat specialist in Darwin,along with audiometric data. Tympanoplastywas arranged for the client without a furtherpre-surgical appointment being required. Case 3 The hearing aid fitting was carried out in aremote area, with the audiologist located ina city hearing centre. A health worker whowas with the client connected the hearingaid to the computer, and placed the real-earmeasurement probe in the ear for insertiongain measures. The audiologist set thehearing aid parameters, evaluated the fittingusing real-ear measures, and made adjust-ments to meet amplification targets. Insertiongain targets were met, and the client reportedsatisfaction with the fitting. Case 4 Case 4 had been fitted with hearing aids, buthad found that they made the sound of children playing noisily outside too loud.(Following the fitting of a hearing aid tomatch the prescription targets, a client needsto gain some experience of wearing thehearing aid in their usual acoustic environ-ments. Personal preferences, or the specificeffects noticed in their own environment, mayinfluence what changes need to be made tothe acoustic parameters of the hearing aids.)During the follow-up appointment at a remotecommunity, a health worker connected theclient’s hearing aid to a computer so that theaudiologist could make adjustments to theoverall gain and to the gain for loud inputs(i.e., adjust the compression ratio). Via theVCU, the audiologist also discussed hearingtactics with the client. Case 5 At a hearing aid follow-up appointment, Case5 explained that he was happy with the hear -ing aids in all situations, but had difficultyreplacing the batteries and inserting the earmoulds into his ears. The audiologist providedinstructions and demonstrations via the VCU,leading to an immediate correction of theproblem. This appointment would normallynot have occurred for another two monthswere a personal appointment required. DISCUSSION This pilot confirmed that it is feasible forhearing services to be provided to peoplelocated in remote regions via tele-audiologymethods. The services on trial were limited tohearing assessment, hearing aid adjustment,and rehabilitative counselling for adultclients. Before tele-audiology can achievewidespread adoption for clinical serviceprovision, the effectiveness of the provisionof these services via tele-audiology methodswill need to be evaluated to ascertain thatthey are equal in quality to those provided inperson (American Speech-Language-HearingAssociation, 2005a, 2005b, 2005c).Currently, a major limitation in deliveringa comprehensive service from diagnosis tointervention for hearing loss is the need forqualified clinicians to take ear impressions,which are for used to make makingcustomised ear moulds for individuals whorequire them for hearing aid fitting. Due tomedico–legal implications, a qualified clini-cian must carry out the task in person. Itmay, however, be possible to make earmoulds by by using high-resolution scanningof the ear canal instead of taking an earimpression. High-resolution scanning may inthe future be conducted from a remote siteby a health worker,and transmitted to acentral region for processing, where informa-tion about the structure of the ear canal canbe derived for the purpose of making earmoulds (personal communication, SiemensHearing Instruments, 2009). The effective-ness of this approach for making customisedear moulds will need to be determined. The cases described above have indicatedthat hearing aid fitting and fine-tuning can becarried out remotely. Maintenance of thedevices, however, relies on the effectiveness of the local health worker in performing minortrouble-shooting, and knowing about the WENDY PEARCE, TERESA Y.C. CHING AND HARVEY DILLON 98  battery requirements of the range of hearingaids fitted to individual clients on site. Further investigations into the use of tele-audiology for providing hearing services tochildren will be valuable. Assessmenttechniques for young children are much morecomplex than those for adults. Children lessthan three years of age are not developmen-tally ready to respond to a hearing assess-ment by traditional audiometric testing. Atest battery approach is required, includingtympanometry, otoacoustic emissions andbehavioural assessment. Behavioural assess-ment for young children needs to be carriedout by specialist audiologists using anoperant conditioning paradigm with visualreinforcement (Birtles, 1989), with speciallydesigned equipment and software. AustralianHearing has recently put together a portablesystem that enables infant hearing assess-ment to be carried out in nonsoundproof rooms. The system comprises an audiometerand a portable DVD player for providingvisual reinforcement, and insert earphones orsupra-aural earphones positioned insidenoise-excluding earmuffs. The effectivenessof this method will be examined in futureinvestigations. Further work on the use of tele-audiologyneeds to include investigations into workingwith other health programs, training localpersonnel, and developing a raft of systematicguidelines and protocols. Work is underwayto develop guidelines for the best way of identifying communities with the greatestinterest and ability in participating in serviceprovision via tele-audiology. Provision of services relies on having good communityconsultation, suitable communication net -works, and a health worker in the communitywho can support the service. The effective-ness of providing a remote hearing service inconjunction with other health programs isalso unknown. In our experience, this canprovide some financial benefit in terms of sharing travel and accommodation costs. Itmay also allow for introductions to be madeby a known person within a communitywhere a service is new. Working with other PROVISION OF HEARING SERVICES USING TELE-AUDIOLOGY 99 healthcare programs may also assist inproviding insights into the best practices fortele-audiology.The pilot investigations of the use of tele-audiology for the provision of hearingservices to remote areas of Australia haveshown benefits in the timeliness of serviceprovision. After a systematic evaluation of the quality of services, it will be possible toimplement components of the pilot work into routine service provision to remotecommunities. ACKNOWLEDGMENTS The authors would like to thank colleaguesfrom Australian Hearing, Sydney Children’sCochlear Implant Centre, Hear and SayCentre, Macquarie University, Royal Institutefor Deaf and Blind Children, Ear ScienceInstitute Australia, University of WesternAustralia, and University of Melbourne.special thanks are extended to Emma Scanlan,who ran the project examining this aspect of remote service provision. REFERENCES American Speech-Language-Hearing Association.(2005a).  Audiologists providing clinical services viatelepractice: Position statement  .American Speech-Language-Hearing Association.(2005b).  Audiologists providing clinical services viatelepractice: Technical report  .American Speech-Language-Hearing Association.(2005c). Knowledge and skills needed by audiolo-gists providing clinical services via telepractice .Birtles, G. (1989). A visual reinforcement orientationscreening procedure.  Australian Journal of  Audiology , 11(1) , 1–9. Choi, J., Lee, H., Park, C., Oh, S.,& Park, K. (2007). PCbased tele-audiometry. Telemedicine and eHealth,13(5) , 501–508.Eikelboom, R., Mbao, M., Coates, H., Atlas, M., &Gallop, M. (2005). Validation of tele-otology todiagnose ear disease in children. International  Journal of Paediatric Otorhinolaryngology , 69 ,739–744.Krumm, M. (2007). Audiology telemedicine.  Journal of Telemedicine and Telecare, 13, 224–229.Krumm, M., Huffman, T., Dick, K.,& Klich, R. (2008).Telemedicine for audiology screening of infants.  Journal of Telemedicine and Telecare, 14, 102–104.  WENDY PEARCE, TERESA Y.C. CHING AND HARVEY DILLON 100 Polovoy, C. (2008). Audiology telepractice overcomesinaccessibility. The ASHA Leader, 13(8) , 20–22.Siemens Hearing Instruments. (personal communication,2009).Smith, A., Dowthwaite, S., Agnew, J.,& Wooten, R.(2008). Concordance between real-time telemedicineassessments and face-to-face consultations in paedi-atric otolaryngology.  Medical Journal of Australia,188 (8) , 457–460.Symantic. (1995).  pcAnywhere User’s Guide . Documen -tation, version 10.5.1.Wesendahl, T. (2003). Hearing aid fitting: Application of telemedicine in audiology.  International Tinnitus Journal, 9(1) , 56–58.
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