Research explores pros and cons of teleaudiology

Teleaudiology works best with patients who already have a well­established relationship with their audiologist. Recent research in Canada also suggests that teleaudiology — which involves interacting electronically with patients, such as via the Internet — can benefit patients who live in areas with few audiologists.

Older patients who have difficulty getting around might also benefit from teleaudiology. The technology can also assist clinicians by making it easier for them to consult with other audiologists about complex cases. Those are some of the conclusions from research led by Dr. Gurjit Singh, a post­doctoral fellow at the Toronto Rehabilitation Institute and the University of Toronto. He presented an overview of his findings at the Canadian Academy of Audiology’s annual conference last fall in Victoria, B.C. Health policy makers are excited about the potential for telemedicine in general to reduce wait times and health care costs, he told the gathering. Unfortunately, the research into telemedicine hasn’t been encouraging. A 1999 study by Marc Berg of Erasmus University in Rotterdam found that 75 per cent of telemedicine interventions ultimately fail. Subsequent meta­analyses by other researchers reached similar conclusions, Dr. Singh said. When it comes to teleaudiology, though, there’s been a “relative absence” of research. So Dr. Singh set out to change that, in collaboration with Marissa Molkowski and Kathy Pichora­Fuller at the University of Toronto, as well as with researchers at Phonak in Switzerland, specifically Michael Boretzki and Stefan Launer, and Rex Banks, chief audiologist of the Canadian Hearing Society. In his talk, Singh cited four studies he and his colleagues were involved in: a qualitative study based on in­depth interviews with 11 hearing professionals; a quantitative study based on questionnaires answered by 202 hearing professionals (152 were audiologists; the rest were hearing instrument specialists); a study of 87 U.S. audiology students; and a study of a survey of 308 patients of hearing professionals. From the qualitative research, Singh and his colleagues found advantages and disadvantages to teleaudiology.

Accessibility

Foremost among the potential advantages was “that teleaudiology could increase accessibility to hearing health care services,” especially for people living in remote or under­serviced locations. Secondly, “for many individuals, particularly older adults, transportation is an issue,” even if they live in densely populated areas. And related to that were clients with mobility concerns, “who actually have difficulty physically getting in to the office, independent of their transportation issues.” From the practitioners’ perspective, teleaudiology might also create opportunities for audiologists to reach patients outside of their catchment areas, or maintain relationships with patients who move away. “This was something that sort of flipped me a little bit,” Dr. Singh said.

Teleaudiology might also make it easier for clinicians to consult with colleagues about complex cases, thus benefiting from each other’s expertise. Professionals also talked about the potential conveniences of teleaudiology, such as enabling more rapid responses, and allowing more efficient interaction with patients restrained by their work schedules. “One way for teleaudiology to increase convenience is taking into account the differences in schedules for our clients,” Dr. Singh said. This speed of access, and reduction in wait times, might also make it easier for patients to maintain their hearings. “Any time you remove some of those barriers then people are more likely to pursue follow­up that they need,” Dr. Singh quoted the chief audiologist of a private network of clinics. Other potential benefits Singh cited from the research were helping patients to maintain their independence; and reducing their financial burdens, by cutting down on travel costs, for example.

Financial opportunity

On the other hand, teleaudiology presents a financial opportunity for audiologists, who might connect with new patients in underserved areas. Nunavut, for example, is the size of Mexico but has only one audiologist. “There’s also a number of potential disadvantages and virtually every one of the disadvantages we heard through these interviews were related to quality of care,” Dr. Singh said. Most of those comments concerned rapport and trust, “that teleaudiology could be a threat to the relationship quality,” he said. In many cases, that was described as a “gut feeling.” However, he also quoted an audiologist with 18 years experience who said: “You almost need to be in the [client’s] presence to understand their body language and eye contact and their tone.” On the other hand, there appeared to be minimal concerns about confidentiality. And the concerns expressed also had elements of ambiguity. “People might be reluctant to disclose something personal once they get into this telecommunications modality. But there is also evidence from the literature that people are more willing to reveal information in these types of environments.” In a similar way, the literature for medicine in general suggests that people are more likely to reveal information to specialists than to their family doctors because of the potential for embarrassment. The technology itself presents other pitfalls, such as when a clinician is multitasking on the computer. “What happens when you start having this communication with a patient when you’re on a computer where there might be other applications that are open at the moment?” Dr. Singh said. Meanwhile, face­to­face meetings offer opportunities for patient interaction once a session is over. “That walking to the desk, walking away from the desk, getting out the door, just going down a hallway with a person — those are all opportunities for incidental communication with that patient,” he said. In a video conference, though, “you hit click, the conversation’s ended.”

The power of touch

Telemedicine also doesn’t allow for physical comforting and reassuring of a patient. Singh started taking mental note of how often he touches his patients while adjusting a hearing aid or during an ear examination. “I do it fairly often. I’m touching my patients, putting my hand on their back, reassuring them, and I wasn’t even aware of just often I did that. And I think it’s important.” For the most part, the qualitative study showed a high­degree of comfort with using teleaudiology for counselling, oral rehabilitation, and screening. It also showed moderate comfort levels for auditory brainstorm response testing, audiometry, and followup assessments. However, most of those interviewed were not comfortable with using teleaudiology to perform assessments or do first fittings. “This isn’t an either­or­thing,” Dr. Singh said as he summarized a theme of his presentation. “This is one of those tools to complement the existing practice.” Good candidates for teleaudiology would be patients with minor issues, those who couldn’t come to an appointment because of bad weather, and snowbirds who have gone south for the winter, as well as staff at longterm care facilities. Poor candidates would include less technology savvy people, especially in cases where they have to drive much of the technology. Most of those interviewed said it would be a bad idea to book teleaudiology appointments for children. However, one professional strongly disagreed with that sentiment. “And I’m tempted to trust this individual,” Dr. Singh said. The participants in the qualitative study consisted of nine audiologists, one physician and one audiology student. Of the audiologists, six were male and three were female. Six of the audiologists has master’s degrees, one had an AuD., and another a PhD. Five worked in private practice and four in public settings. It was the first time Dr. Singh had done qualitative analysis. “All my experiments before that were lab­based, presenting thousands of trials to individuals in carefully controlled experiments,” he said. While he found the qualitative data, “incredibly rich and valuable,” the self­confessed “hard­core scientist” wanted to confirm the qualitative conclusions with quantitative analysis. Singh and his colleagues also conducted a study with researchers in the U.S. that involved 87 AuD. students. There was almost no difference in the attitudes of the students and the Canadian practitioners. “The conclusion: I didn’t need to do this study apparently because we got it all in the qualitative data,” he said, adding that “This ice cold heart has been melted.”

Keith Norbury

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