As a general rule of life and technology, in particular, tradition eventually takes a backseat to innovation, convenience, and mobility every single time. Examples of this are all around us, in every industry — a prime example being Landline Telephones in America. In 2005, 90% American households had a landline phone. Cut to December 2016, and the figure dropped to less than 46%, as per the estimates from the National Health Interview Survey July-Dec 2016.
A similar phenomenon is slowly, but surely, unfolding in the global health care delivery system — particularly in Audiology — where telemedicine is shaking things up by bridging the doctor-patient geographical divide.
Telemedicine — The way forward
Very broadly, this is the exchange of medical information from one physical location to another through electronic modes of communication with the ultimate aim of improving a patient’s clinical health. Although still in its relative infancy, the field has made tremendous advancements in recent years, thereby reducing barriers to optimal care in underserved areas, helping medical practitioners expand their practice reach, and enabling patients to access to high-quality care without having to travel long distances.
Today the use of this technology is growing exponentially as more hospitals, clinics and health care professionals understand its benefits, and advanced teleaudiology tools are being developed. It is now being integrated into existing operations to improve patient care and enhance overall outcomes while simultaneously augmenting revenue.
What services can be catered to?
Primary care and specialist referral services
This may involve a primary health care professional providing direct consultation to a patient or a specialist assisting the primary care physician in rendering a diagnosis either through live video conferencing or via store-and-forward telecommunication services.
Remote patient monitoring (RPM)
This involves the use of digital technologies to remotely collect patient health data from individuals and have that information shared electronically with a health care provider or a remote diagnostic testing facility (RDTF) for interpretation and recommendation. Remote patient monitoring could potentially supplement the use of visiting nurses.
Consumer medical and health information
This enables patients to obtain specialised health information and access online discussion groups that provide peer-to-peer support through the use of the Internet and wireless devices.
Besides helping health professionals continue their medical education, this technology can help in providing special medical education seminars for targeted groups in remote locations.
What Are the Benefits?
Not only does it help patients have better access to healthcare, but it also allows physicians and health-care facilities to expand their reach beyond their office walls.
Significantly reduced cost of healthcare and enhance efficiency by effectively reducing the time and money spent on travels and making hospital stays fewer or shorter.
It is now possible for patients in rural, remote and underserved areas to get access to high-quality health professionals, thereby significantly augmenting the level of health care service delivered.
Using these technologies reduces travel time and give patients in far-fetched areas access to providers that might not be available otherwise, as well as medical services without the need to travel long distances.
Before we go into detail and discus how it is making an impact and reshaping the way hearing healthcare services are being delivered worldwide, let us first understand how deep a problem disabling hearing loss (DHL) really is. (source)
Disabling Hearing Loss — A Global Health Scourge
World Health Organization (WHO) in a study conducted in 2013 estimates that over 5% of the global population (360 million people) suffer from Disabling Hearing Loss (DHL). Out of this number, 328 million are adults and 32 million children. Furthermore, the report estimates that 60% of the childhood hearing loss arise from causes that could have been averted with early identification and professional intervention. Geographically, DHL is most prevalent in South Asia, the Asia Pacific region and Sub-Saharan Africa where health care facilities are few and far between. (source)
Prevalence of disabling hearing loss (DHL) decreases exponentially as gross national income per capita (GNI) increases. (source)
Focusing on South Africa
As per a 2011 census report (source) conducted by Statistics South Africa, 3.6% of the population suffers from hearing difficulties with children and senior citizens being the most affected. The key points of the survey relating to hearing disabilities uncovered the following:
- The national profile shows that about 3% of persons aged 5 years and older had mild difficulty in hearing, while those who experienced severe difficulty in hearing constituted less than 1%.
- Severe hearing difficulty was more prevalent among the older ages. The proportion of persons with severe difficulty in hearing was highest among persons aged 85+ years (10%).
Issues around the provision of hearing healthcare services
While types of hearing impairment can vary from conductive impairment to sensorineural impairment, timely medical intervention can restore normal hearing or help in rehabilitation through the use of hearing aids and special training. However, it is early identification and accurate diagnosis that form the basis of medical intervention. In fact, as we mentioned earlier, early identification and accurate diagnosis can result in the prevention of 60% of the childhood hearing loss cases. But there are a number of issues that prevent effective delivery of hearing health care services in both developing and developed nations that this relatively new technology can potentially eradicate.
Issues that harm hearing healthcare delivery
Shortage of trained hearing healthcare professionals
As per WHO estimates, the number of audiologist per capita is between 1 audiologist per 0.5 million people to 1 audiologist per 6.25 million in the developing world. Developing countries lack an adequate number of medically trained personnel, let alone appropriately trained individuals to perform a basic hearing assessment, device fitting, and/or rehabilitation. In sharp contrast to these figures, developed countries have at least 1 audiologist per 20,000 people. The ratio density of audiologists in developing to developed countries is 300:1. These shortages of hearing healthcare professionals are primarily due to a reported lack of government funding, professional and public awareness, and, most significantly, available training programs (Goulios & Patuzzi, 2008).
- Absence of physical and institutional infrastructure
- Healthcare infrastructure, in both developing and developed nations, is primarily clustered around metropolitan locales.
- Geographical and Political Challenges
- Financial and Logistical Barrier
- Elderly ‘immobile’ Population
- Ethnic and linguistic diversity
- Cultural apathy towards hearing loss
- Unavailability of low-cost hearing aid solutions
The question now becomes how does Audiology evolve to rise up to these challenges and create an inclusive hearing healthcare delivery system that does not alienate a majority of those who are severely affected by DHL.
Telemedicine in Audiology — A Transformative Solution
Audiologists are challenged to find ways to differentiate themselves and draw patients to their practices/clinics. Adopting technology to provide hearing healthcare from a distance might be the critical factor that the profession needs in order to grow beyond its current reach. Moreover, convenience and mobility are becoming key factors influencing consumer decisions whether for apparel or for health care services such as audiology.
More importantly, it must be understood that the need for audiology solutions worldwide far exceeds the profession's capacity to deliver — specifically in the areas of education & training, screening, diagnosis and intervention
A global perspective
As outlined in an earlier section, a sizeable chunk of the global population — approximately 360 million people — are living with permanent DHL who would immensely benefit from hearing health services.
Unfortunately, the majority of people around the world with DHL conditions, live in regions where hearing healthcare is inaccessible (or, worse, non-existent). Telemedicine based services have the potential to help meet the demand for hearing healthcare and more importantly, make these services more easily available, especially in remote areas.
Pros & Cons
- Given the dearth of trained hearing health professionals and the pressing need for hearing health care, this technology presents a way to make a mark on global hearing health-care delivery
- Complex cases can be addressed quicker through consultations between clinicians
- Remote areas would be within reach for hearing healthcare services
- Older or differently abled patients can access hearing health care from the comfort of their homes rather than physically coming to the clinic/hospital for treatment
- From a business perspective, It opens up the target market with patients traditionally outside the catchment area now coming within reach
Other Possible Benefits
- Increase access to healthcare
- Reduce wait time
- Reduce medical travel
- Minimize caregiver stress/time off work
- Facilitate rapid response
- Reduce CO2 emissions
- Reduce costs of delivering health care
- Increase comfort when discussing stigmatizing issues
- Improve clinical outcomes
- Improve adherence to treatment
- Some professionals feel quality of care is not the same
- Telemedicine does not allow for physical comforting and reassuring of a patient
- Disadvantageous for diagnostic testing
- Disadvantageous with children
- Disadvantageous for building relationships with new patients
Here are excerpts from an interview conducted with Dirk Koekemoer — Inventor, disruptor, medical doctor and CEO of eMoyo. He seeks to take healthcare to the billions in need.
In your experience, how successful is Tele-Audiology as a means to deliver hearing healthcare in rural and remote areas?
It is proving its efficacy in a few large-scale projects around the world. One such project, the largest of its kind, is the South African MDR-TB ototoxicity project. A large-scale, national project that monitors the effects of medication on patients with TB. This technology combined with automation enables nursing staff to test patients without an audiologist being present. Audiologists are able to track testing and advice remotely.
This has enabled us to detect ototoxicity and intervene early on, to protect patients hearing. It has also boosted the capacity of audiologists and enabled distributed services, despite a shortage.
What are the biggest challenges in delivering audiological services in the rural and remote areas of the world?
Accessibility is one of the biggest challenges. Traditional equipment requires a sound booth and trailer for testing. This makes accessing remote areas more difficult and cost-prohibitive. In some cases, patients are tested without a sound booth. This then means that noise is able to affect test results. Resulting in increased false referrals and referral rates, which affects patients who must travel to towns or cities to access clinics, hospitals, and specialists. Both false and incorrect referrals force patients to return home without treatment and at great expense.
There is a worldwide shortage of audiologists. It is not efficient to have trained specialists travelling to remote areas where technology could do the same job.
How significant has the role been of portable audiometers like KUDUwave™ in furthering services in remote/rural and under-served areas?
The KUDUwave™ is vital in enabling hearing testing in under-served areas. It combines the sound booth, audiometer, and headset in a single, lightweight device. This makes hearing testing available anywhere in the world and enables audiologists to service remote locations without compromising on quality. Creating employment through training KUDUwave™ operators, we open a world of opportunities at the same time.
How do audiological societies and regulating bodies tend to view this technology?
They are excited about the possibilities but also nervous that new technology may make the industry obsolete by placing hearing testing capabilities in the hands of non-audiologists. With such a world wide shortage of audiological professionals there is very little chance of this happening, we prefer to focus on helping to make the existing professionals as efficient as possible and enable them to reach more patients with quality care than is currently possible with ordinary equipment.
We have written about these concerns here: /why-audiology-isn't-a-dodo
What's the future you envisage for the hearing healthcare delivery system in remote/rural areas?
We envisage a future where hearing care is no longer seen as an epidemic or a problem, but an opportunity to create employment for many while servicing the needs of the millions who don't, currently, have access to care and treatment. We imagine a future where multiple small businesses offer hearing testing services with only a KUDUwave™, laptop, and a scooter. They offer their services at a fee, supported by audiologists from anywhere in the world and together reach the masses.
Scope of Application Possibilities for Tele Audiology
Education and Training
Parents, paraprofessionals, and health care providers can benefit from real-time telecommunication via live video conferencing or telehealth. Individuals being trained will be guided through procedures and helped to gain a broadened understanding of atypical cases. Alternatively, pre-recorded videos may be sent via email or other online means and information may be requested from trained personnel in the field who will respond later.
Telehealth in Audiology also has applications in screening for hearing for occupational safety purposes, to determine newborn hearing and also screening hearing for entry to school. Vestibular screening may also be conducted via these means as a comprehensive way to identify patients with a concussion.
In synchronous screening, clinicians in remote locations are present on a live video feed to provide directives and support for each procedure. Other trained personnel may be present at the testing site to assist in the administration of the procedure as the needs dictate. Application sharing allows for the real-time processing and monitoring of the screening procedure and also for instructions to be given.
For asynchronous or indirect screening, processes such as Otoacoustic Emissions and Auditory Brainstem Response screening are automated and other hearing tests via the internet may be utilized.
Telehealth applied in Audiology is used to make diagnoses in a multiplicity of cases. During surgical procedures, obtaining case histories, in otoscopy via video conferencing, audiometry, vestibular diagnosis, AEP and OAE, a combination of synchronous video conferencing and remote application sharing is used.
To achieve diagnosis by asynchronous means, the patient’s case history can be obtained via electronic entry of the information and subsequent forwarding or storage. A similar approach may be used for video otoscopy where the information upon testing is then stored or forwarded to the audiology practice for analysis. Other diagnostic methods previously mentioned may be automated and treated in a similar manner. Alternatively, all relevant information collected or recorded may be stored to a unique patient file electronically.
The application of telehealth in audiology may be further applied to intervention where assistance can be sought to address any problematic outcomes. Synchronously, counselling can be provided via live video conferencing at which time troubleshooting can also be explored.
Ear canal management can also be done via video under the oversight of an audiologist. Hearing aids may also be selected, fitted and programmed, while cochlear implants can be mapped and activated remotely, through guided video and application sharing. Follow up and early intervention sessions may also be performed via this live protocol.
To apply audiological telehealth intervention by asynchronous means, videos may be recorded to address concerns, queries or other issues the patient may have which would have been sent to the audiologist ahead of time.
Some treatment programs may be administered by these means as well as training, counselling and even early intervention in infantile cases. Hearing aids may also be selected and programmed ahead of the remote indirect session on the basis of the results obtained from diagnostic testing.
Remote Hearing Test — A Real World Telemedicine Example
This case study was performed on a group of thirty persons (12 males and 18 females) residing in Pretoria in sub-Saharan Africa, the method of remote auditory testing to determine hearing sensitivity was carried out over a range of six acoustic frequencies between 250 and 8000 Hz. This testing revealed the promise that remote testing holds for patients afflicted with the condition in countries where the facilities are either limited or non-existent.
The setup utilized involved the use of a portable KUDUwave™ audiometer which had insert earphones. The audiometer was connected to the internet-enabled computer which would also record the pure tone air conduction measurements. The insert earphones were then covered with outer earphones to reduce the effect of environmental noises on the test. All of this was manned by a trained doctor who ensured that the equipment was being properly used and to also monitor the computer setup.
The final link in the chain was a Skype connection between that location and a clinician located in Dallas who then administered the procedure remotely through communication with the test subjects. The computer in Pretoria was controlled by this clinician through an application sharing software, which allowed for direct access to the computer system. Privacy protocols were observed through password enabled connections on both ends.
To preserve the integrity and reliability of the remote procedure, each test subject was dealt with in an identical manner as was the case with the test procedure. Both ears were tested for each subject. The results obtained were compared by means of a test conducted across frequencies (125-8000 Hz) to determine whether there was a significant degree of difference between the usual method of testing and remote testing.
The comparisons revealed that while remote audiological testing takes 21% longer than face to face testing, this did not significantly affect the test results. The variance between face to face and remote results is within acceptable limits and can open doors for audiological testing in underserved areas.
The consistency obtained regarding the level of variation between face to face and remote testing times is quite promising and so many countries around the world can look forward to benefiting from this technology in the future.
Tele-audiology is happening right now...but there are teething problems
- Both patient and audiologist need to have access to the internet
- Some tech understanding is required as a phone, tablet or laptop + a software application will be utilized for treatment
- Wireless hearing aids will be required to connect the audiologist to the patient.
- When a technician is required, several concerns arise: cost-effectiveness, privacy issues, HIPPA, and less control by the audiologist
- Hearing aids are becoming wireless and the good ones connect to a phone application. As this technology proliferates, all patients will have access to remote hearing aid programming
- The internet is exploding in developing nations and as patients become accustomed to telemedicine, technicians may need not be physically present
- Full diagnostic tests, including bone conduction and speech testing, will be completed reliably and remotely