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The Role of Tele-audiologyin Supporting Access to CareEHDI MeetingApril 16, 2013Glendale, AZDiane Behl, NCHAMAnne Marie Tharpe, Vanderbilt UniversityDeborah Hayes, Children’s Hospital ColoradoVicki Hunting, Iowa EHDI program

Role of Tele-audiology in EHDI Increased access to diagnostic evaluations reducing loss to follow up Include interpreters and cultural brokers Support culturally competent services Provide remote hearing aid management, CIprocedures timely intervention

Learning Community Purpose:Share, Expand, CreateOrganizational/politicalprocessesTechnology nuts & boltsInterpersonalprocedures

Learning Community Members CaliforniaCanadaColoradoIowaTennesseeWisconsinUtah

Key Factors Building partnerships, laying groundwork Ensuring secure, high-quality servicedelivery Family-centered services Reimbursement Resources

Tele-Audiology in GuamImproving Access to Care from 7,000 MilesAway!Deborah Hayes, Ph.D.University of Colorado School of MedicineChildren’s Hospital ColoradoNational EHDI ConferenceApril 16, 2013

HAFA ADAI!GUAM: A FEW FACTS U.S. Territory acquired in 1898 followingthe Spanish-American War Native people are Chamorro from AsianPacific region Japanese occupation during World War II;re-captured by the U.S. in 1944 U.S. military presence with Naval and AirForce Bases Semi-tropical island about 30 miles x 8miles in size Civilian population of 170,000 Birthrate for 3,300 infants/year“Fiber Optic Flower” on aBeachfront Tree

Purpose of this Presentation Describe why tele-audiology for infant diagnostic audiological evaluations(DAE) was considered for the Guam EHDI program Enumerate steps in the process of launching a tele-audiology practice ininfant DAEs Identify issues specific to the practice of tele-audiology Discuss personnel, hardware, and software requirements for our project Describe test results to date Summarize challenges and solutions in tele-audiology practice

Loss to Follow-up at DAE in GuamSlide courtesy of Elaine Eclavea, M.Ed., University of Guam

Issues in Completing Infant DAEsLack of Audiologist comfortable in testing newbornsRepeated AABR screensEquipmentParent refusalProcess taking too longParents seeking testing off-islandLack of enrollment into early intervention programs

Possible SolutionsFind an audiologist on island or within the PacificregionNo university training program in GuamOn-island audiologists fully committed with jobresponsibilities, unavailable to civilian population, ornot well-experienced in infant DAEs“Transient” audiologist who could fly to Guamseveral times/year for testingOption of tele-audiology

Tele-audiology for Infant DAEProviding infant DAEs over the internet emerged from apresentation and subsequent discussion with EHDI coordinatorsfrom the Pacific Rim including Guam, Palau, Federated States ofMicronesia, Saipan, and Commonwealth of Northern MarianaIslands at EHDI Meeting (2010)Guam was selected as the pilot site becauseSufficient birthrate to ensure enough babies to test the conceptAvailability of organized screening and early intervention programsAdequacy of internet and travel services to facilitatecommunication and interaction

Steps in the ProjectDeveloping of a Memorandum of Understanding outlining each party’sresponsibilitiesVisiting site of tele-audiology in Guam by Children’s Hospital Colorado staffEvaluate test environment and equipmentTrain Guam-based technicians (DOE audiometrists)Develop procedures jointlyAcquiring Guam audiology licensureIdentifying HIPAA-compliant software for remote control of Guam diagnosticaudiometric equipment and videoconferencingTesting/retesting software solutionsEnsuring a successful first tele-audiology testScheduling a Children’s Colorado audiologist on Guam for “Go Live”

Issues in Tele-audiology PracticeProfessional licensingChildren’s Colorado audiologists obtained a Guam audiology license priorto testingPrivacy and confidentialityRemote control software is approved as secure for testing over theinternet by Children’s Colorado; no infant identifying information istransmitted during testingVideoconferencing software encrypts audio and video transmissionLiability and malpracticeChildren’s Colorado audiologists are covered by the hospital’s liabilityinsurance policyInformed consent is obtained from parents prior to testing

Personnel for Tele-audiologyIn ColoradoTwo licensed (Colorado and Guam) audiologists from Children’sHospital ColoradoProject leadershipTechnical supportIn GuamTrained technicians (Guam DOE-Part B audiometrists)Project leadership from Guam EHDITechnical supportGuam Family Supporters from Guam Early Intervention Services(GEIS)

Technology for Tele-audiologyIn Guam:Bio-logic Navigator PRO (NavPRO) for auditory brainstemresponse, otoacoustic emissions, auditory steady stateresponseGSI TympStar and Interacoustics Titan for tympanometryand middle ear muscle reflexesLaptop for videoconferencingIn Colorado:Desktop PC for remote control operation of NavPROLaptop for videoconferencing

Software for Tele-audiologyNetop Remote Control software for audiologist in Coloradoto “take control” of Guam NavPROColorado is “guest” and logs into Guam NavPRO through public IPaddressGuam is “host” and allows Colorado to take control of NavPRONo infant identifying information is transmitted during testingNefsis videoconferencing softwareGuam holds Nefsis videoconferencing licenseColorado connects to videoconference established by Guam viasecure website

First “Go Live” in GuamA mother holds her infant duringteleaudiology testing to determinewhether or not her infant has a hearingloss. Technology enabled Dr. ErickaSchicke at Children's Hospital-Coloradoto operate the diagnostic audiologicalequipment remotely from Colorado, afterBobbie Maguadog (left), Department ofEducation audiometrist, and Dr. SusanDreith (center), audiologist, Children'sHospital-Colorado, prepared the parentand infant for testing on Guam. (Photocredit: University of Guam)

Tele-audiology Results to DateXX test sessions completed to date (March 21, 2013)XX infants received complete diagnostic assessment; Xinfant received partial ABRbut did not sleep for remaining tests Otoscopy (by Guam audiometrist)TympanometryOtoacoustic emissionsAuditory brainstem response (air and bone conduction as needed)Auditory steady state response (air and bone conduction as needed)Diagnosis and recommendations provided to family by testing audiologistFormal report generated by testing audiologist for family and primary medicalproviderAudiological diagnosis facilitated referral for medical services for XX infantsXX additional infants scheduled for April 2013

Challenges in Tele-audiologyIdentifying an appropriate test environmentIdentifying and training support personnelScheduling appointments across time zones (16 hourdifference between Colorado and Guam)Interruption of internet services during testingMeasuring effectiveness of family counseling delivered byvideoconferencingIntegrating infant DAE services into full EHDI program toattain quality outcomesSustaining services beyond pilot phase

What We have LearnedInfant diagnostic audiological evaluations can be effectivelyprovided over the internetSite visit(s) is/are critical to success of tele-audiologySoftware solutions must meet contemporary standards forinfant and family privacy and confidentialityTele-audiology is optimally delivered within the context ofcomprehensive services for the infant or patient and familyTele-audiology can be a successful approach for providingservices in rural and remote communities

Tele-Audiology in IowaVicki HuntingProject Director, Improvement AdvisorChild Health Specialty Clinics (CHSC)Partnership to Improve Child Health in Iowa (PI CHI)Early Hearing Detection & Intervention (EHDI)Assuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Iowa DemographicsAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Iowa EHDI HRSA Grant – University of Iowa, Department of Pediatrics,Child Health Specialty Clinics (CHSC)– Hands & Voices, Guide By Your Side (GBYS) for Family Support– Technical Assistance from Audiologists @ Center for Disabilities& Development (CDD), Iowa’s University Center for Excellence inDevelopmental Disabilities (UCEDD)– Long Term Follow-up CDC Grant – Iowa Department of Public Health (IDPH)– Surveillance/Data– Relationship with birthing centers– Short Term Follow-upAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Set-up “Hub “in Iowa City @CDD with Audiologists “Spoke” in Oelwein @CHSC Regional Center(RC) with RNAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Equipment Vivosonic Integrity @ Spoke site (Oelwein)GoToAssist – Spoke & Hub (Iowa City/Oelwein)Polycom – Spoke & Hub (Iowa City/Oelwein)Hi Def flat screen monitorAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Iowa Process1. Child does not pass 2nd screen (OP)2. Proximity to CHSC Oelwein RC3. Appointment is scheduled4. Appointment attended5. Test is complete6. Results shared - on the spot7. Next Steps/Referrals8. Community Resources and additional services shared.9. Results documented in state database & UIHC EMR10. Follow-upAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Audiological ServicesPrior to the Appointment: Audiologist/RN meet discuss appt Configuration test, setup connections, ensure workingorderDuring the Appointment: RN may repeat OAE screen if warranted RN Puts on electrodes Otoscopy @ Spoke Click thresholds Tone bursts thresholds Future: Include capacity for high frequency tympAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Community Services Oelwein RegionalCenter also employsSocial Workers, FamilyNavigators, on site Access to Hands &Voices Guide By YourSide (GBYS) Parent anddeaf/hard of hearingGuidesAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

What’s Important to Families Communication Communication Communication!!!!Knowing what to expect from thisTele-Audiology experienceCommunication during testing aboutwhat’s happeningCommunicating with otherprofessionals, their families aboutresultsServing and understanding diverseculturesRecords, results andcounseling/family supportWhat happens nextCommunity supports and servicesavailable to themOut-of-pocket costs/InsuranceAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

ReimbursementToday Grant activity Everything is within University of Iowa Hospitals and Clinics (UIHC),Department of Pediatrics Family pays nothing (okay for now, low referrals) RN @ spoke site– nursing licensure board says this is within RN “scope of practice”Future Challenge, reimbursement for tele-health in Iowa Arranging reimbursement from third party payers;– Medicaid, private insurersAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Challenges MarketingReferralsStable Bluetooth connectionsThird Party ReimbursementSustainabilityAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Contact InformationVicki Hunting515-331-0750Vicki-hunting@uiowa.eduAssuring a System of Care for Iowa’s Children and Youth with Special Health Care Needs

Teleaudiology: The VanderbiltPerspectiveAnne Marie TharpeDevin McCaslinRene GiffordGina AngleyVanderbilt Bill Wilkerson CenterVanderbilt University School of Medicine

Steps to Take:1.2.3.4.5.6.Identify area(s) of needFind project partnersSet goalsOperationalize processDetermine technical/equipment needsAssess/re-assess

Examples from Vanderbilt

Project I: Remote NewbornHearing Screening

Identify Areas of NeedMadisonCoShelbyCoHamilton Co

BuildingI think you’vewaited too latePartnershipsto find me!