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Telehealth Technology Applications in Speech-Language Pathology
Casey Stewart Keck, MA,1 and Charles R. Doarn, MBA2
Key words: telehealth, telepractice, telerehabilitation, speechlanguage pathology, technology, communication disorders
Despite being immersed in advanced technologies and a majority (64%)29 of Americans being connected to the Internet, the field of speech-language pathology (SLP) has been slow to utilize available technologies to expand services to individuals who would otherwise be restricted. SLP practitioners are anxious to adopt these technologies but have encountered barriers such as limited reimbursement, state licensure laws, and medical information privacy laws. Moreover, SLP practitioners are confronted with the hurdle of evolving face-to-face (FTF) clinical practices into effective telehealth practice adapted to the current national infrastructure. Telehealth service delivery models can be divided into two categories: store-and-forward technology (asynchronous) and the use of real-time technology (synchronous). A hybrid model is emerging, and SLP practitioners are combining these two technologies to overcome infrastructure shortcomings affecting the ability to make sound clinical decisions.5,7,11–13,20,21,25–28 Telehealth infrastructure encompasses connectivity (how telecommunications are accessed) and equipment (what devices are used to enable telecommunications). Internet-based videoconferencing software enables two-way audio and video communication and is currently the primary synchronous method.30 However, factors such as costs, availability of resources, and diagnostic/intervention and patient needs should be considered when selecting the telehealth infrastructure for service delivery. Standards governing the delivery of SLP services using telehealth have not yet been formally established. However, the American Speech-Language-Hearing Association’s Telepractice Working Group has published documents providing information and guidance for the implementation of telecommunication technology in the field of SLP.31 The American Telemedicine Association is also a valuable resource for ethical, clinical, technical, and administrative standards with application across telehealth settings.32 Although telehealth can be an extension of telemedicine, evidence documenting the efficacy, cost benefits, and sustainability is needed for development of standards and widespread adoption. Understanding the new role of technology in the diagnosis and treatment of communication disorders is vital for the expansion of telehealth as a standard of care. The purpose of this article is to overview the current technologic infrastructure and procedures for telehealth applications in SLP and the innate challenges and opportunities.
Introduction
Materials and Methods
A
A literature search was conducted for telehealth publications in the field of SLP. Cross-disciplinary search engines, including PubMed, CINAH, ERIC, and PsycINFO, were searched using terms or combination of terms closely related to SLP: ‘‘telespeech,’’
1
Department of Communication Sciences and Disorders, College of Allied Health, University of Cincinnati, Cincinnati, Ohio. 2 Department of Family and Community Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Abstract Introduction: Speech-language pathologists are anxious to adopt telehealth technologies but have encountered barriers such as limited reimbursement, state licensure laws, and medical information privacy laws. Moreover, speech-language pathologists are confronted with the hurdle of evolving face-to-face clinical practices into effective telehealth practice adapted to the current national infrastructure. Factors such as costs, availability of resources, and diagnostic/intervention and patient needs should be considered when selecting the telehealth infrastructure for service delivery. Understanding the new role of technology in the diagnosis and treatment of communication disorders is vital for the expansion of telehealth as a standard of care. The purpose of this article is to overview the current technologic infrastructure and procedures for telehealth applications in speech-language pathology (SLP) and the innate challenges and opportunities. Materials and Methods: A literature search was conducted for telehealth publications in the field of SLP. Given the rapid rate at which technology advances, only peerreviewed articles published over the past 5 years (2008–2013) were included. Results: The majority of articles reviewed used hybrid methodologies to maintain traditional SLP service standards. General technological components for telehealth activities included computers, Web cameras, headsets with an embedded microphone, and Internet connectivity. Conclusions: Advanced technology has limitations in the application of telehealth. Technological adversities were not reported as the cause of discontinuation of telehealth services by the practitioner or the individual. Audio and visual disturbances were primarily associated with videoconferencing. Supplemental asynchronous technology was widely reported as a solution to real-time instabilities.
growing body of research advocates the use of telecommunication technologies to expand speech-language pathology (SLP) services,1–28 but only 7% of Americans reported using the Internet for telehealth applications.29
DOI: 10.1089/tmj.2013.0295
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Table 1. Technology Summary DIAGNOSIS/ DISORDER
MODEL
DEVICEa
VTCb
WEB CAMERAc
HEADPHONES/ SPEAKERSd
MICROPHONEe
Dysphagia and/or communication impairments; head and neck cancer
S, A
A4
B2
C7
D7
E7
1 Mbps
No
n = 3; 13–16 yo
Fluency
S, A
A1P, A1
B1
C1P
D1P
E1P
SLP used cable broadband Internet; participants reportedly had ‘‘Internet.’’
No
Ciccia et al.4
n = 263; speechlanguage pathology screenings; children up to 6 yo
Speech, language, and hearing screenings
S
A1
B1
C3
D1
E1
Not specified
No
Constantinescu et al.5
n = 61; 52–89 yo
Voice disorders due to Parkinson’s disease
S, A
A1
B3
C1
D2
E2
128 Kbps
No
Constantinescu et al.6
n = 34; 54–85 yo
Voice disorders due to Parkinson’s disease
S, A
A1
B3
C1
D2
E2
128 Kbps
No
Constantinescu et al.7
n = 1; 65 yo
Voice disorder due to Parkinson’s disease
S, A
A1
B3
C1
D2
E2
128 Kbps
No
Goldberg et al.9
n = 2; 41–49 yo
Aphasia
S, A
A1P, A3
B1
C1
D1
E1
Not specified
No
1
1
1
1
Educational network at a minimum bandwidth of 10 Mbps
No
REFERENCE
PARTICIPANTS
Burns et al.1
n = 18; 42–80 yo
Carey et al.3
GroganJohnson et al.10
n = 38; 4–12 yo
Articulation, language, and/or fluency disorder
Hill et al.11
n = 24; 16–78 yo
Dysarthria
1
S
A
B
S,A
A1
B3
C2
D2
E2
128 Kbps
Yes
1
3
2
2
2
128 Kbps
Yes
128 Kbps
Yes
Broadband Internet
Yes
12
n = 11; 16–78 yo
Apraxia of speech
S,A
A
B
Hill et al.13
n = 32; 21–80 yo
Aphasia
S,A
A1
B3
1
Hill et al.
Howell et al.
14
Lasker et al.15
1
C
C
D
D
E
BANDWIDTH SECURITY
E
C2
D2
E2
1
CP
1
DP
1
EP
n = 3; 63–72 yo
Voice disorder due to Parkinson’s disease
S,A
AP
B
n = 1; 28 yo
Apraxia of speech
S,A
A1
B1
C1
D2
E2
N/A
No
Not specified
No
Broadband Internet
Yes
1
Malandraki et al.16
n = 17; 35–76 yo
Dysphagia
A
A
N/A
N/A
NA
N/A
Malandraki et al.17
n = 32; 50–75 yo
Dysphagia
S,A
A1
B2
C1
D6
E6
Riegler et al.19
n = 12; 20–43 yo
Cognitivecommunication disorders; mild traumatic brain injury
S,A
A1
B4
N/A
N/A
N/A
Wireless Internet
Yes
Sharma et al.20
n = 10; standardized patients
Simulated dysphagia
S,A
A1
B3
C5, C6
D5
E4, E5
128 Kbps wireless network
No
Theodoros et al.21
n = 32; 21–80 yo
Aphasia
S,A
A1
B3
C2
D2
E2
128 Kbps
Yes
Turkstra et al.22
n = 20; 21–69 yo
Cognitivecommunication disorders; traumatic brain injury
S
A1, A4
B1, B2
C4, C7
D1, D7
E1, E7
512 Kbps and 900 Kbps
No
continued/
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Table 1. Technology Summary continued REFERENCE
DIAGNOSIS/ DISORDER
24
n = 10; 49–70 yo
Dysphagia and/or communication impairment; head and neck cancer
Ward et al.25
n = 40; 25–94 yo
Waite et al.26
Ward et al.
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PARTICIPANTS
MODEL
DEVICEa
VTCb
WEB CAMERAc
HEADPHONES/ SPEAKERSd
4
2
2
7
3G phone network; 3.5 Mbps
No
D5
E4, E5
128 Kbps wireless network
No
C2
D2
E2
128 Kbps
Yes
B3
C2
D2
E2
128 Kbps
Yes
A1
B3
C2
D3
E2
128 Kbps
Yes
1
1
4
4
3
3-Mbps wireless-3G connection or standard cable-Internet
No
Not specified
No
A
B
Dysphagia
S,A
A1
B3
C5, C6
n = 20; 8–13 yo
Childhood literacy disorders
S, A
A1
B3
Waite et al.27
n = 25; 5–9 yo
Receptive and expressive language disorder
S, A
A1
Waite et al.28
n = 20; 4–9 yo
Speech disorder
S, A
Furr et al.
Cherney et al.37
Summative information provided; n = 13; 4–25 yo
Craniofacial; speech evaluations and therapy
n = 32; 23–76 yo
Aphasia
BANDWIDTH SECURITY
E7
S
34
MICROPHONEe
S
A
B
S, A
A1
B3
C
C
C1
D
D
D1
E
E1
a 1
A , personal computer; A1P, participant’s computer; A3, participant’s mobile phone; A4, proprietary.
b 1
B , low-cost software (e.g., Skype); B2, proprietary hardware (e.g., Polycom 7000s); B3, proprietary custom; B4, TeleVyou 500SP videophone (plain old telephone service).
c 1
C , unspecified; C1P, unspecified participant’s Web camera; C2, QuickCam Pro 4000, Logitech; C3, Microsoft Life Cam VX-3000; C4, integrated; C5, fixed sphere camera MP AF, Logitech; C6, unspecified freestanding; C7, proprietary. d 1
D , unspecified; D1P, unspecified participant’s headset (headphones with microphone) or speakers; D2, unspecified headset; D3, AHS202i headset, Altec; D4, unspecified speakers; D5, Duet Executive, Phoenix Web conference speaker; D6, telephone; D7, proprietary; NA, not available. e 1 E , unspecified; E1P, unspecified participant’s microphone; E2, part of headset; E3, integrated; E4, free-field combined echo canceling; E5, CK55L, AKG lapel microphone; E6, telephone; E7, proprietary.
A, asynchronous; Kbps, kilobits per second; Mbps, megabits per second; S, synchronous; SLP, speech-language pathologist; VTC, videoconference; yo, years old; Yes, security features overviewed; No, security features not specified.
‘‘telepractice,’’ ‘‘telehealth,’’ ‘‘telemedicine,’’ ‘‘telerehabilitation,’’ ‘‘speech therapy,’’ ‘‘speech pathology,’’ ‘‘swallowing,’’ ‘‘speech,’’ and ‘‘language.’’ Given the rapid rate at which technology advances, only peer-reviewed articles published over the past 5 years (2008–2013) were included. In addition, the articles reviewed used advanced technologies and contained sufficient information regarding the technology used for delivery of SLP services.
Results The search resulted in 26 peer-reviewed articles. Hybrid methods were used in the majority (n = 20; 77%) of articles reviewed, whereas synchronous accounted for 19% (n = 5), and asynchronous accounted for 4% (n = 1). Depending on the communication disorder and type of services needed, equipment varied from mobile phones to proprietary systems (e.g., Polycom [San Jose, CA]). Internet connectivity included low bandwidth at 128 kilobits per second (Kbps) to the highest reported bandwidth of 10 megabits per second (Mbps), and both lowcost and custom videoconference software has been used. Use of peripheral devices ranged from external headsets to high-quality
hand-held cameras. General technological components for telehealth activities included computers, Web cameras, headsets with an embedded microphone, and Internet connectivity. Table 1 gives details. The articles were divided into clinical specialties.
CHILDHOOD SPEECH AND LANGUAGE DISORDERS Historically, school districts have been prone to SLP practitioner shortages affecting the quality of services, delivery of appropriate services, and workload of school-based SLP practitioners.33 Telehealth offers solutions by enabling remote delivery of services to underserved schools, professional collaboration, and reduced travel time for SLP practitioners with multiple appointments. A recent survey of school-based SLP practitioners revealed an increase in the use of telepractice from 1% in 2010 to 4% in 2012.33 Telehealth has been shown to be an effective model for standardized and informal assessments,26–28 screenings,4 and treatment10 of various childhood speech and language disorders. A pilot study, conducted in a rural Ohio school district, provided articulation and language treatment using PC-based videoconferencing
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transmitted over a 10-Mbps Internet connection to students with communication disorders. Visual materials were displayed by the SLP practitioner using a document camera, and headsets were given to the students. Trained facilitators provided tech support, maintained attendance logs, communicated with the remote SLP practitioner, and disseminated and collected therapy materials from the child.10 Urban community-based clinics in Ohio conducted speech and language screenings focused on articulation, receptive and expressive language, and play/social behavior over Skype (Luxembourg) videoconference software using similar basic technology, a laptop computer, and a Web camera.4 In a series of studies conducted at the University of Queensland, Brisbane, Australia, researchers used a PC-based system with customized software to demonstrate the potential of telehealth for standardized assessment of literacy skills,26 receptive and expressive language,27 and screening of speech intelligibility and oral motor structure and function.28 The PC-based system allowed SLP practitioners to videoconference, over a 128-Kbps Internet connection, with children who were equipped with headphones and microphones. Web cameras, mounted on a motorized base above the child’s monitor, were controlled by the online SLP practitioner and enabled the professional to concurrently view the child and video-record the assessment.26–28 The SLP practitioner monitored the child and electronic stimulus materials simultaneously on two monitors. Electronic stimulus files were displayed by the SLP practitioner and included prerecorded audio, video, text files, and scanned images of text files. Verbal responses were captured via the headset microphone, and all audio recordings were automatically stored on the child’s computer first and then forwarded to the SLP practitioner.26–28 Lastly, a capacitive touch screen displayed the child’s touch responses on the SLP practitioner’s monitor and then stored and forwarded the data to the professional’s computer.26,27
CRANIOFACIAL Multidisciplinary postoperative care for individuals with cleft lip/ palate is critical, and for people in developing countries, access to these services is limited. Telehealth, however, has the potential to bridge the distance between trained specialists in developed countries and individuals in remote regions. Multidisciplinary teams in the United States have recently explored the potential of telehealth to provide pre- and postoperative speech evaluations and speech therapy internationally to individuals with cleft lip/palate.34 Summations of their experiences describe the use of low-cost videoconferencing (iChat; Apple, Cupertino, CA) over high-speed (3 Mbps) wireless-3G or standard commercial cable-Internet and off-the-shelf technology, computers equipped with Web browsing software, audio speakers, an integrated Webcam, and a microphone, as essential equipment.34 Real-time sessions were supported by facilitators at the remote sites who assisted with administrative and technical support.
clinical trial, researchers at the Australian Stuttering Research Centre at the University of Sydney demonstrated the viability of combining Internet videoconferencing and asynchronous technology to deliver the Camperdown Program to adolescents who stutter.3 Treatment was delivered via Skype and recorded by the SLP practitioner using Pamela, a Skype add-on. Home practice speech samples were recorded using the audio editor Audacity (developed at Carnegie Mellon University, Pittsburgh, PA) and e-mailed to the SLP practitioner.
VOICE DISORDERS To date, work in telehealth and voice has pertained to individuals with voice disorders due to Parkinson’s disease. Diagnosis and management of voice disorders via telehealth present unique technological challenges. Analysis of voice relies on perceptual judgments, objective acoustic and aerodynamic measurements, and, laryngeal imaging. In order for services to be completely remote, technology must be capable of transmitting voice signals over the Internet without compromising their acoustic integrity. This is important for acoustic and perceptual analysis. Efficacious analysis via telehealth has required synchronous methods to be supplemented with FTF services,14 asynchronous technology,5–7,14 and/or advanced software.5–7 A pilot study conducted by researchers in the United Kingdom showed the feasibility of using Skype videoconferencing to deliver the Lee Silverman Voice Treatment (LSVT) to participants with voice disorders due to Parkinson’s disease.14 Web-based sessions were conducted using broadband Internet videoconference and the participant’s home PC, Web camera, and headset with microphone. Supplementing the videoconference sessions was a weekly FTF session conducted in the participant’s home to objectively measure sound pressure (loudness), establish a therapeutic relationship, and to review home practice materials.14 Recordings collected during FTF and Skype sessions, using HotRecorder (www.hotrecorder.com), were forwarded to participants using e-mail for guided practice. A custom PC-based telehealth system developed at the University of Queensland achieved remote standardized and informal assessment5 and treatment6,7 of speech and voice disorders associated with Parkinson’s disease. The PC-based telehealth equipment and software capabilities used in the voice literature5–7 were similar with those used for studies of childhood speech and language disorders.26–28 Customized software supported videoconferencing (320 · 240 pixel resolution),5,7 electronic data sharing, and the SLP practitioner’s remote control of the Web camera. Additional features enabling remote delivery of services for voice disorders included (a) the ability to capture high-quality video (640 · 480 pixel resolution)5–7 and audio recordings (384 Kbps)5–7 separate from videoconferencing, (b) review of synchronous files as needed, and (c) viewable samples of real-time calibrated average measures of loudness, pitch, and duration data via an acoustic speech processor. Participants were not required to interact with the software as all features were either automatic or SLP practitioner directed.5,7
FLUENCY The use of low-tech telehealth technology such as plain old telephone service and postal service mail, has previously been used to deliver fluency interventions to adults and children.35,36 In a Phase I
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NEUROGENIC COMMUNICATION DISORDERS Neurogenic communication disorders are the result of brain insult or disease processes and can affect language (aphasia) understanding
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and formation, speech production (dysarthria and apraxia), and cognitive functions. Differential diagnosis of neurogenic communication disorders is crucial for appropriate management; therefore, telehealth methods have incorporated flexibility and usability of technology. Valid and reliable standardized and informal assessment of dysarthria,11 aphasia,13,21 and apraxia of speech12 were demonstrated using a custom PC-based telehealth system developed at the University of Queensland.5–7,26–28 The system’s software enabled videoconferencing over 128 Kbps supplemented with asynchronous audio and video.11–13,21 Electronic data sharing permitted display of instructional images and video clips11–13,21 and touch responses.12,13,21 The SLP practitioner controlled recording of high-resolution highquality video footage and audio files independent of the videoconference, as well as remote camera positioning. Participants were not required to interact with the software.11–13,21 Less sophisticated technology was shown to be effective for assessment of discourse ability in adults with posttraumatic brain injury.22 Although equipment and connectivity varied between two settings (Table 1), assessments were conducted using videoconferencing software (i.e., iChat) and hardware (e.g., Polycom 7000s) over high-speed Internet (512 Kbps or maximum of 900 Kbps) connectivity. Videoconferencing occurred over both platform-specific equipment and computers. No differences in video or audio quality or transmission speed between the two settings’ telehealth systems were reported.22 A facilitator was present with the participants to monitor safety and equipment, in addition to assisting with task materials. Telehealth has also enabled efficient,19 intensive,9,15,37 and individualized9,15,37 management of neurogenic communication disorders. A case study examined the use of Skype to deliver a portion of SLP services to an adult with severe apraxia of speech.15 Videoconferencing was conducted using PCs, headsets, and recorded using Call Recorder software (www.ecamm.com/mac/callrecorder/). Recordings were used to assess progress, and telehealth was supplemented with FTF sessions. Similarly, researchers at the University of North Carolina at Chapel Hill have demonstrated the feasibility of using Skype videoconferencing for a portion of therapy sessions aimed to deliver a modified script training intervention to adults with aphasia. This study also used asynchronous independent home practice using the participant’s PC or mobile phone.9 Soldiers with mild traumatic brain injury who were previously noncompliant with traditional therapy were shown to be adherent to cognitive rehabilitation therapy using videophone (used plain old telephone service) intervention combined with self-guided Webbased learning modules.19 Modules were accessed via computer and included didactic video clips, cognitive strategies, and homework. People with aphasia used virtual therapist software to complete a structured language intervention in their home setting both asynchronously and synchronously when an SLP practitioner monitored in real-time.37 The virtual software was accessed via the SLP practitioner’s and participant’s computers through the Internet. Software features included the option of real-time communication, customization, and store-and-forward progress monitoring.37 Family mem-
bers or caregivers underwent training to provide technology support for participants.
DYSPHAGIA Swallowing difficulties (dysphagia) can cause serious health complications such as malnutrition, aspiration, and potentially death.38 SLP practitioners’ interventions have been shown to improve swallowing safety, thus reducing the length of hospital stays and decreasing expenses related to pneumonia and other pulmonary complications.38 Dysphagia assessments can use both instrumental and clinical examination. Concurrent with FTF standards, remote assessment requires evaluation of oral and laryngeal structure/ function and trials with varying consistencies of food and liquid. The current telehealth infrastructure limits the type of procedures that can be accomplished remotely; therefore, studies have investigated balancing technology with facilitators.20,25 Limited availability of adequately trained SLP practitioners in instrumental swallowing assessments is a global concern. Real-time transmission of videofluoroscopic swallowing studies (VFSS) was achieved using PC-based videoconference hardware over broadband Internet.17,18 Communication between the fluoroscopy suite and the remote SLP practitioner was conducted using a speaker telephone. Store-and-forward technology enabled repeated viewing of the VFSS images and was controlled by the remote SLP practitioner.17,18 In an international pilot study, VFSS were performed and recorded by less experienced practitioners in Athens, Greece and then uploaded to a Web site for an expert SLP practitioner’s consultation at Columbia University in the United States. A virtually lossless compression codec was used to maintain video fidelity. The expert SLP practitioner retrieved the information via the Web site 1 day after the evaluation was conducted in Greece.16 Clinical swallowing evaluations were effectively administered using a custom videoconferencing system with facilitator assistance.20,25 The telehealth system was composed of two notebook computers equipped with custom videoconferencing software using high-quality audio and video compression technology over a 128-Kbps bandwidth and storeand-forward technology.20,25 The participant’s system was portable and required no technological interaction. Web cameras allowed concurrent visualization of the participant and the SLP practitioner. The participant’s Web camera was freestanding on an adjustable mobile platform and enabled remote control and zoom by the SLP practitioner. Split-screen imaging allowed concurrent viewing of the participant and SLP practitioner. Communication occurred through a free-field combined echo-cancelling microphone and Web conference speaker.20,25 The participant’s voice quality was captured and recorded using a lapel microphone. A finger pulse oximeter was used to measure the participant’s oxygen saturation throughout the assessment. The facilitator’s role was to perform tasks under the SLP practitioner’s direction, to evaluate and relay haptic and/or missed information to the SLP professional, and to adjust the equipment as necessary.20,25 Similar technology was used for swallowing and communication evaluations with head and neck cancer1 and post-laryngectomy24 patients. Mobile telehealth systems enabled videoconferencing over a
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3.5-Mbps 3G wireless phone network24 and 1 Mbps.1 External cameras captured high-quality video and still images. Hand-held medical cameras (Flexi dock 200; Inline Medical and Dental Pty., Sydney, Australia) with general imaging and intraoral probes were also used for close examination of the stoma and oral cavity.1 Split-screen imaging allowed simultaneous viewing of the participant and the SLP practitioner.1,24 Additional lighting sources enhanced visualization of examined structures.1,24 The technology was either remotely controlled or operated by the SLP practitioner.1,24 Store-and-forward technology enabled consultation with specialists.1
Discussion TECHNOLOGY CHALLENGES Advanced technology has limitations in the application of telehealth. Mashima and Doarn39 highlighted the importance of selecting connectivity mediums, bandwidth, and equipment based on desired clinical outcomes. Low bandwidth, network congestion, latency, low frame rate, and pixilation, reportedly caused occasional variability in audio and video quality and/or delays between audio and visual images during videoconferencing.5–7,9,11–14,20,21,24–28 Fluctuations in connectivity minimally resulted in session disconnection.21,24,37 Other drawbacks like audio static and echo,5,26 equipment malfunctions,1,6,24,37 reliance on the participant’s technology,3,14 and participant’s limited technology experience14 were described. Technological adversities were not reported to result in the practitioner’s or the individual’s discontinuation of telehealth services. Audio and visual disturbances were primarily associated with videoconferencing. Supplemental asynchronous technology was widely reported as a solution to real-time instabilities.5–7,11–13,20,21,25–28
FUTURE DIRECTIONS Although access to technology is rapidly expanding, digital prosperity is not equally distributed. Demographics can be determinative; for instance, individuals from low-income households and rural areas are less likely to own a computer and implement broadband connectivity.29 Smartphone ownership continues to rise,29 and mobile health is emerging as an effective medium for connecting individuals with healthcare professionals and enabling management of their own care.40 Future research should consider the viability of using mobile health not only to expand SLP services to individuals lacking the current telehealth infrastructure, but also to enable intervention in the context of everyday life events. Development of technical standards and guidelines is critical for appropriate and effective implementation of telehealth.39,41 Further research investigating the fidelity of equipment specifications and positioning, telehealth candidacy, and environment characteristics is warranted to assist in the development of professional standards. Moreover, inclusion of cost–benefit analyses is needed to justify telehealth reimbursement.
Conclusions The application of technology in SLP is growing. Evidence supporting the technical feasibility of telehealth to deliver SLP services
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has been demonstrated.1–28 SLP practitioners engaged in telehealth activities are responsible for providing the same quality of services via telehealth as they would be FTF.31 The infrastructure of telehealth is a significant component of telehealth models of delivery. Therefore, it is essential that SLP practitioners be educated on the successful implementation of technology, challenges that have been encountered, and future applications.
Acknowledgments The authors would like to thank Dr. Lisa Kelchner and Dr. Nancy Creaghead for their assistance and support.
Disclosure Statement No competing financial interests exist.
REFERENCES 1. Burns CL, Ward EC, Hill AJ, et al. A pilot trial of speech pathology telehealth service for head and neck cancer patients. J Telemed Telecare 2012;18:443– 446. 2. Werts R, Dronkers N, Bernstein-Ellis E, et al. Appraisal and diagnosis of neurogenic communication disorders in remote settings. Clin Aphasiol 1987;17:117–123. 3. Carey B, O’Brian S, Onslow M, Packman A, Menzies, R. Webcam delivery of the Camperdown Program for adolescents who stutter: A Phase I trial. Lang Speech Hear Serv Schools 2012;43:370–380. 4. Ciccia AH, Whitford B, Krumm M, et al. Improving the access of young urban children to speech, language and hearing screening via telehealth. J Telemed Telecare 2011;17:240–244. 5. Constantinescu G, Theodoros D, Russell T, et al. Assessing disordered speech and voice in Parkinson’s disease: A telerehabilitation application. Int J Lang Commun Disord 2010;45:630–644. 6. Constantinescu G, Theodoros D, Russell T, et al. Treating disordered speech and voice in Parkinson’s disease online: A randomized controlled non-inferiority trial. Int J Lang Commun Disord 2011;46:1–16. 7. Constantinescu GA, Theodoros DG, Russell TG, et al. Home-based speech treatment for Parkinson’s disease delivered remotely: A case report. J Telemed Telecare 2010;16:100–104. 8. Duffy JR, Werven GW, Aronson AE. Telemedicine and the diagnosis of speech and language disorders. Mayo Clin Proc 1997;72:1116–1122. 9. Goldberg S, Haley KL, Jacks A. Script training and generalization for people with aphasia. Am J Speech Lang Pathol 2012;21:222–238. 10. Grogan-Johnson S, Alvares R, Rowan L, et al. A pilot study comparing the effectiveness of speech language therapy provided by telemedicine with conventional on-site therapy. J Telemed Telecare 2010;16:134–139. 11. Hill AJ, Theodoros D, Russell T, et al. The redesign and re-evaluation of an Internet-based telerehabilitation system for the assessment of dysarthria in adults. Telemed J E Health 2009;15:840–850. 12. Hill AJ, Theodoros D, Russell T, et al. Using telerehabilitation to assess apraxia of speech in adults. Int J Lang Commun Disord 2009;44:731–747. 13. Hill AJ, Theodoros D, Russell T, et al. The effects of aphasia severity on the ability to assess language disorders via telerehabilitation. Aphasiology 2009;23:627–642. 14. Howell S, Tripoliti E, Pring T. Delivering the Lee Silverman Voice Treatment (LSVT) by web camera: A feasibility study. Int J Lang Commun Disord 2009;44;287–300. 15. Lasker JP, Stierwalt JAG, Spence M, et al. Using webcam interactive technology to implement treatment for severe apraxia: A case sample. J Med Speech Lang Pathol 2010;18:71–75.
TELEHEALTH TECHNOLOGY IN SLP
16. Malandraki GA, Markaki V, Georgopoulos VC, et al. An international pilot study of asynchronous teleconsultation for oropharyngeal dysphagia. J Telemed Telecare 2013;19:75–79. 17. Malandraki GA, McCullough G, He X, et al. Teledynamic evaluation of oropharyngeal swallowing. J Speech Lang Hear Res 2011;54;1497–1505.
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18. Perlman AL, Wtthawaskul W. Real-time remote telefluoroscopic assessment of patients with dysphagia. Dysphagia 2002;17:162–167. 19. Riegler LJ, Neils-Strunjas JN, Boyce S, et al. Cognitive intervention results in web-based videophone treatment adherence and improved cognitive scores. Med Sci Monitor 2013;19:269–275. 20. Sharma S, Ward EC, Burns C, et al. Assessing swallowing disorders online: A pilot telerehabilitation study. Telemed J E Health 2011;17:688–695. 21. Theodoros D, Hill AJ, Russell T, et al. Assessing acquired language disorders in adults via the Internet. Telemed J E Health 2008;14:552–559. 22. Turkstra L, Quinn-Padron M, Johnson J, et al. In-person versus telehealth assessment of discourse ability in adults with traumatic brain injury. J Head Trauma Rehabil 2012;27:424–432. 23. Vaughn G, Amber W, Bess J, et al. Efficacy of remote treatment of aphasia by tel-communicology. Rehabil R & D Prog Rep 1987;25:432–433. 24. Ward E, Crombie J, Trickey M, et al. Assessment of communication and swallowing post-laryngectomy: A telerehabilitation trial. J Telemed Telecare 2009;15: 232–237. 25. Ward EC, Sharma S, Burns C, et al. Validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment via telerehabilitation. Dysphagia 2012;27:460–472. 26. Waite MC, Theodoros DG, Russell TG, Cahill LM. Assessment of children’s literacy via an Internet-based telehealth system. Telemed J E Health 2010;16:564–575.
32. Brennan D, Tindall L, Brown J, et al. A blueprint for telerehabilitation guidelines. American Telemedicine Association. Available at www.americantelemed.org/ docs/default-source/standards/a-blueprint-for-telerehabilitation-guidelines .pdf?sfvrsn = 4 (last accessed August 9, 2013). 33. Janota J. 2012 schools survey. American Speech-Language-Hearing Association. 2012. Available at www.asha.org/uploadedFiles/Schools-2012-SLPWorkforce.pdf#search = %22school%22 (last accessed August 9, 2013). 34. Furr MC, Larkin E, Blakely R, et al. Extending multidisciplinary management of cleft palate to the developing world. J Oral Maxillofac Surg 2011;69:237–241. 35. Lewis C, Packman A, Onslow M, et al. A Phase II Trial of telehealth delivery of the Lidcombe Program of Early Stuttering. Am J Speech Lang Pathol 2008;17:139–149. 36. Carey B, O’Brian S, Onslow M, et al. Randomized controlled non-inferiority trial of a telehealth treatment for chronic stuttering: The Camperdown Program. Int J Lang Comm Dis 2010;45:108–120. 37. Cherney LR, Kaye RC, Hitch RS. The best of both worlds: Combining synchronous and asynchronous telepractice in the treatment of aphasia. Perspect Neurophysiol Neurogen Speech Lang Disord 2011;21:83–93. 38. Ashford JR, Logemann JA, McCullough G. Treatment efficacy summary. American Speech-Language-Hearing Association. Available at www.asha.org/ uploadedFiles/public/TESDysphagiainAdults.pdf#search = %22dysphagia%22 (last accessed August 11, 2013). 39. Mashima PA, Doarn CR. Overview of telehealth activities in speech-language pathology. Telemed J E Health 2008;14:1101–1117. 40. Poropatich R, Lai E, McVeigh F, et al. The U.S. army telemedicine and m-health program: Making a difference at home and abroad. Telemed J E Health 2013;19:380–385. 41. Mashima PA, Brown J. Remote management of voice and swallowing disorders. Otolaryngol Clin North Am 2011;44:1305–316.
27. Waite MC, Theodoros DG, Russell TG, Cahill LM. Internet-based telehealth assessment of language using the CELF-4. Lang Speech Hear Serv Sch 2010;41:445–458.
29. National Telecommunications and Information Administration, Economics and Statistics Administration, U.S. Department of Commerce. Exploring the digital nation. America’s emerging online experience. Available at www.ntia.doc.gov/ files/ntia/publications/exploring_the_digital_nation_-_americas_emerging_online_ experience.pdf (last accessed August 9, 2013).
Address correspondence to: Casey Stewart Keck, MA Department of Communication Sciences and Disorders College of Allied Health University of Cincinnati 3202 Eden Avenue Cincinnati, OH 45267
30. Reynolds AL, Vick JL, Haak NJ. Telehealth applications in speech-language pathology: A modified narrative review. J Telemed Telecare 2009;15:310–316.
E-mail: [email protected]
28. Waite MC, Theodoros DG, Russell TG, Cahill LM. Assessing children’s speech intelligibility and oral structures and functions via an Internet-based telehealth system. J Telemed Telecare 2012;18:198–203.
31. American Speech-Language-Hearing Association. Professional issues in telepractice for speech-language pathologist. 2010. Available at www.asha.org.policy/PI2010-00315.htm (last accessed June 21, 2013).
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Received: September 3, 2013 Accepted: October 15, 2013
NO. 7 JULY 2014
TELEMEDICINE and e-HEALTH 659
Telehealth Technology Applications in Speech-Language Pathology
Casey Stewart Keck, MA,1 and Charles R. Doarn, MBA2
Key words: telehealth, telepractice, telerehabilitation, speechlanguage pathology, technology, communication disorders
Despite being immersed in advanced technologies and a majority (64%)29 of Americans being connected to the Internet, the field of speech-language pathology (SLP) has been slow to utilize available technologies to expand services to individuals who would otherwise be restricted. SLP practitioners are anxious to adopt these technologies but have encountered barriers such as limited reimbursement, state licensure laws, and medical information privacy laws. Moreover, SLP practitioners are confronted with the hurdle of evolving face-to-face (FTF) clinical practices into effective telehealth practice adapted to the current national infrastructure. Telehealth service delivery models can be divided into two categories: store-and-forward technology (asynchronous) and the use of real-time technology (synchronous). A hybrid model is emerging, and SLP practitioners are combining these two technologies to overcome infrastructure shortcomings affecting the ability to make sound clinical decisions.5,7,11–13,20,21,25–28 Telehealth infrastructure encompasses connectivity (how telecommunications are accessed) and equipment (what devices are used to enable telecommunications). Internet-based videoconferencing software enables two-way audio and video communication and is currently the primary synchronous method.30 However, factors such as costs, availability of resources, and diagnostic/intervention and patient needs should be considered when selecting the telehealth infrastructure for service delivery. Standards governing the delivery of SLP services using telehealth have not yet been formally established. However, the American Speech-Language-Hearing Association’s Telepractice Working Group has published documents providing information and guidance for the implementation of telecommunication technology in the field of SLP.31 The American Telemedicine Association is also a valuable resource for ethical, clinical, technical, and administrative standards with application across telehealth settings.32 Although telehealth can be an extension of telemedicine, evidence documenting the efficacy, cost benefits, and sustainability is needed for development of standards and widespread adoption. Understanding the new role of technology in the diagnosis and treatment of communication disorders is vital for the expansion of telehealth as a standard of care. The purpose of this article is to overview the current technologic infrastructure and procedures for telehealth applications in SLP and the innate challenges and opportunities.
Introduction
Materials and Methods
A
A literature search was conducted for telehealth publications in the field of SLP. Cross-disciplinary search engines, including PubMed, CINAH, ERIC, and PsycINFO, were searched using terms or combination of terms closely related to SLP: ‘‘telespeech,’’
1
Department of Communication Sciences and Disorders, College of Allied Health, University of Cincinnati, Cincinnati, Ohio. 2 Department of Family and Community Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Abstract Introduction: Speech-language pathologists are anxious to adopt telehealth technologies but have encountered barriers such as limited reimbursement, state licensure laws, and medical information privacy laws. Moreover, speech-language pathologists are confronted with the hurdle of evolving face-to-face clinical practices into effective telehealth practice adapted to the current national infrastructure. Factors such as costs, availability of resources, and diagnostic/intervention and patient needs should be considered when selecting the telehealth infrastructure for service delivery. Understanding the new role of technology in the diagnosis and treatment of communication disorders is vital for the expansion of telehealth as a standard of care. The purpose of this article is to overview the current technologic infrastructure and procedures for telehealth applications in speech-language pathology (SLP) and the innate challenges and opportunities. Materials and Methods: A literature search was conducted for telehealth publications in the field of SLP. Given the rapid rate at which technology advances, only peerreviewed articles published over the past 5 years (2008–2013) were included. Results: The majority of articles reviewed used hybrid methodologies to maintain traditional SLP service standards. General technological components for telehealth activities included computers, Web cameras, headsets with an embedded microphone, and Internet connectivity. Conclusions: Advanced technology has limitations in the application of telehealth. Technological adversities were not reported as the cause of discontinuation of telehealth services by the practitioner or the individual. Audio and visual disturbances were primarily associated with videoconferencing. Supplemental asynchronous technology was widely reported as a solution to real-time instabilities.
growing body of research advocates the use of telecommunication technologies to expand speech-language pathology (SLP) services,1–28 but only 7% of Americans reported using the Internet for telehealth applications.29
DOI: 10.1089/tmj.2013.0295
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Table 1. Technology Summary DIAGNOSIS/ DISORDER
MODEL
DEVICEa
VTCb
WEB CAMERAc
HEADPHONES/ SPEAKERSd
MICROPHONEe
Dysphagia and/or communication impairments; head and neck cancer
S, A
A4
B2
C7
D7
E7
1 Mbps
No
n = 3; 13–16 yo
Fluency
S, A
A1P, A1
B1
C1P
D1P
E1P
SLP used cable broadband Internet; participants reportedly had ‘‘Internet.’’
No
Ciccia et al.4
n = 263; speechlanguage pathology screenings; children up to 6 yo
Speech, language, and hearing screenings
S
A1
B1
C3
D1
E1
Not specified
No
Constantinescu et al.5
n = 61; 52–89 yo
Voice disorders due to Parkinson’s disease
S, A
A1
B3
C1
D2
E2
128 Kbps
No
Constantinescu et al.6
n = 34; 54–85 yo
Voice disorders due to Parkinson’s disease
S, A
A1
B3
C1
D2
E2
128 Kbps
No
Constantinescu et al.7
n = 1; 65 yo
Voice disorder due to Parkinson’s disease
S, A
A1
B3
C1
D2
E2
128 Kbps
No
Goldberg et al.9
n = 2; 41–49 yo
Aphasia
S, A
A1P, A3
B1
C1
D1
E1
Not specified
No
1
1
1
1
Educational network at a minimum bandwidth of 10 Mbps
No
REFERENCE
PARTICIPANTS
Burns et al.1
n = 18; 42–80 yo
Carey et al.3
GroganJohnson et al.10
n = 38; 4–12 yo
Articulation, language, and/or fluency disorder
Hill et al.11
n = 24; 16–78 yo
Dysarthria
1
S
A
B
S,A
A1
B3
C2
D2
E2
128 Kbps
Yes
1
3
2
2
2
128 Kbps
Yes
128 Kbps
Yes
Broadband Internet
Yes
12
n = 11; 16–78 yo
Apraxia of speech
S,A
A
B
Hill et al.13
n = 32; 21–80 yo
Aphasia
S,A
A1
B3
1
Hill et al.
Howell et al.
14
Lasker et al.15
1
C
C
D
D
E
BANDWIDTH SECURITY
E
C2
D2
E2
1
CP
1
DP
1
EP
n = 3; 63–72 yo
Voice disorder due to Parkinson’s disease
S,A
AP
B
n = 1; 28 yo
Apraxia of speech
S,A
A1
B1
C1
D2
E2
N/A
No
Not specified
No
Broadband Internet
Yes
1
Malandraki et al.16
n = 17; 35–76 yo
Dysphagia
A
A
N/A
N/A
NA
N/A
Malandraki et al.17
n = 32; 50–75 yo
Dysphagia
S,A
A1
B2
C1
D6
E6
Riegler et al.19
n = 12; 20–43 yo
Cognitivecommunication disorders; mild traumatic brain injury
S,A
A1
B4
N/A
N/A
N/A
Wireless Internet
Yes
Sharma et al.20
n = 10; standardized patients
Simulated dysphagia
S,A
A1
B3
C5, C6
D5
E4, E5
128 Kbps wireless network
No
Theodoros et al.21
n = 32; 21–80 yo
Aphasia
S,A
A1
B3
C2
D2
E2
128 Kbps
Yes
Turkstra et al.22
n = 20; 21–69 yo
Cognitivecommunication disorders; traumatic brain injury
S
A1, A4
B1, B2
C4, C7
D1, D7
E1, E7
512 Kbps and 900 Kbps
No
continued/
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Table 1. Technology Summary continued REFERENCE
DIAGNOSIS/ DISORDER
24
n = 10; 49–70 yo
Dysphagia and/or communication impairment; head and neck cancer
Ward et al.25
n = 40; 25–94 yo
Waite et al.26
Ward et al.
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PARTICIPANTS
MODEL
DEVICEa
VTCb
WEB CAMERAc
HEADPHONES/ SPEAKERSd
4
2
2
7
3G phone network; 3.5 Mbps
No
D5
E4, E5
128 Kbps wireless network
No
C2
D2
E2
128 Kbps
Yes
B3
C2
D2
E2
128 Kbps
Yes
A1
B3
C2
D3
E2
128 Kbps
Yes
1
1
4
4
3
3-Mbps wireless-3G connection or standard cable-Internet
No
Not specified
No
A
B
Dysphagia
S,A
A1
B3
C5, C6
n = 20; 8–13 yo
Childhood literacy disorders
S, A
A1
B3
Waite et al.27
n = 25; 5–9 yo
Receptive and expressive language disorder
S, A
A1
Waite et al.28
n = 20; 4–9 yo
Speech disorder
S, A
Furr et al.
Cherney et al.37
Summative information provided; n = 13; 4–25 yo
Craniofacial; speech evaluations and therapy
n = 32; 23–76 yo
Aphasia
BANDWIDTH SECURITY
E7
S
34
MICROPHONEe
S
A
B
S, A
A1
B3
C
C
C1
D
D
D1
E
E1
a 1
A , personal computer; A1P, participant’s computer; A3, participant’s mobile phone; A4, proprietary.
b 1
B , low-cost software (e.g., Skype); B2, proprietary hardware (e.g., Polycom 7000s); B3, proprietary custom; B4, TeleVyou 500SP videophone (plain old telephone service).
c 1
C , unspecified; C1P, unspecified participant’s Web camera; C2, QuickCam Pro 4000, Logitech; C3, Microsoft Life Cam VX-3000; C4, integrated; C5, fixed sphere camera MP AF, Logitech; C6, unspecified freestanding; C7, proprietary. d 1
D , unspecified; D1P, unspecified participant’s headset (headphones with microphone) or speakers; D2, unspecified headset; D3, AHS202i headset, Altec; D4, unspecified speakers; D5, Duet Executive, Phoenix Web conference speaker; D6, telephone; D7, proprietary; NA, not available. e 1 E , unspecified; E1P, unspecified participant’s microphone; E2, part of headset; E3, integrated; E4, free-field combined echo canceling; E5, CK55L, AKG lapel microphone; E6, telephone; E7, proprietary.
A, asynchronous; Kbps, kilobits per second; Mbps, megabits per second; S, synchronous; SLP, speech-language pathologist; VTC, videoconference; yo, years old; Yes, security features overviewed; No, security features not specified.
‘‘telepractice,’’ ‘‘telehealth,’’ ‘‘telemedicine,’’ ‘‘telerehabilitation,’’ ‘‘speech therapy,’’ ‘‘speech pathology,’’ ‘‘swallowing,’’ ‘‘speech,’’ and ‘‘language.’’ Given the rapid rate at which technology advances, only peer-reviewed articles published over the past 5 years (2008–2013) were included. In addition, the articles reviewed used advanced technologies and contained sufficient information regarding the technology used for delivery of SLP services.
Results The search resulted in 26 peer-reviewed articles. Hybrid methods were used in the majority (n = 20; 77%) of articles reviewed, whereas synchronous accounted for 19% (n = 5), and asynchronous accounted for 4% (n = 1). Depending on the communication disorder and type of services needed, equipment varied from mobile phones to proprietary systems (e.g., Polycom [San Jose, CA]). Internet connectivity included low bandwidth at 128 kilobits per second (Kbps) to the highest reported bandwidth of 10 megabits per second (Mbps), and both lowcost and custom videoconference software has been used. Use of peripheral devices ranged from external headsets to high-quality
hand-held cameras. General technological components for telehealth activities included computers, Web cameras, headsets with an embedded microphone, and Internet connectivity. Table 1 gives details. The articles were divided into clinical specialties.
CHILDHOOD SPEECH AND LANGUAGE DISORDERS Historically, school districts have been prone to SLP practitioner shortages affecting the quality of services, delivery of appropriate services, and workload of school-based SLP practitioners.33 Telehealth offers solutions by enabling remote delivery of services to underserved schools, professional collaboration, and reduced travel time for SLP practitioners with multiple appointments. A recent survey of school-based SLP practitioners revealed an increase in the use of telepractice from 1% in 2010 to 4% in 2012.33 Telehealth has been shown to be an effective model for standardized and informal assessments,26–28 screenings,4 and treatment10 of various childhood speech and language disorders. A pilot study, conducted in a rural Ohio school district, provided articulation and language treatment using PC-based videoconferencing
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transmitted over a 10-Mbps Internet connection to students with communication disorders. Visual materials were displayed by the SLP practitioner using a document camera, and headsets were given to the students. Trained facilitators provided tech support, maintained attendance logs, communicated with the remote SLP practitioner, and disseminated and collected therapy materials from the child.10 Urban community-based clinics in Ohio conducted speech and language screenings focused on articulation, receptive and expressive language, and play/social behavior over Skype (Luxembourg) videoconference software using similar basic technology, a laptop computer, and a Web camera.4 In a series of studies conducted at the University of Queensland, Brisbane, Australia, researchers used a PC-based system with customized software to demonstrate the potential of telehealth for standardized assessment of literacy skills,26 receptive and expressive language,27 and screening of speech intelligibility and oral motor structure and function.28 The PC-based system allowed SLP practitioners to videoconference, over a 128-Kbps Internet connection, with children who were equipped with headphones and microphones. Web cameras, mounted on a motorized base above the child’s monitor, were controlled by the online SLP practitioner and enabled the professional to concurrently view the child and video-record the assessment.26–28 The SLP practitioner monitored the child and electronic stimulus materials simultaneously on two monitors. Electronic stimulus files were displayed by the SLP practitioner and included prerecorded audio, video, text files, and scanned images of text files. Verbal responses were captured via the headset microphone, and all audio recordings were automatically stored on the child’s computer first and then forwarded to the SLP practitioner.26–28 Lastly, a capacitive touch screen displayed the child’s touch responses on the SLP practitioner’s monitor and then stored and forwarded the data to the professional’s computer.26,27
CRANIOFACIAL Multidisciplinary postoperative care for individuals with cleft lip/ palate is critical, and for people in developing countries, access to these services is limited. Telehealth, however, has the potential to bridge the distance between trained specialists in developed countries and individuals in remote regions. Multidisciplinary teams in the United States have recently explored the potential of telehealth to provide pre- and postoperative speech evaluations and speech therapy internationally to individuals with cleft lip/palate.34 Summations of their experiences describe the use of low-cost videoconferencing (iChat; Apple, Cupertino, CA) over high-speed (3 Mbps) wireless-3G or standard commercial cable-Internet and off-the-shelf technology, computers equipped with Web browsing software, audio speakers, an integrated Webcam, and a microphone, as essential equipment.34 Real-time sessions were supported by facilitators at the remote sites who assisted with administrative and technical support.
clinical trial, researchers at the Australian Stuttering Research Centre at the University of Sydney demonstrated the viability of combining Internet videoconferencing and asynchronous technology to deliver the Camperdown Program to adolescents who stutter.3 Treatment was delivered via Skype and recorded by the SLP practitioner using Pamela, a Skype add-on. Home practice speech samples were recorded using the audio editor Audacity (developed at Carnegie Mellon University, Pittsburgh, PA) and e-mailed to the SLP practitioner.
VOICE DISORDERS To date, work in telehealth and voice has pertained to individuals with voice disorders due to Parkinson’s disease. Diagnosis and management of voice disorders via telehealth present unique technological challenges. Analysis of voice relies on perceptual judgments, objective acoustic and aerodynamic measurements, and, laryngeal imaging. In order for services to be completely remote, technology must be capable of transmitting voice signals over the Internet without compromising their acoustic integrity. This is important for acoustic and perceptual analysis. Efficacious analysis via telehealth has required synchronous methods to be supplemented with FTF services,14 asynchronous technology,5–7,14 and/or advanced software.5–7 A pilot study conducted by researchers in the United Kingdom showed the feasibility of using Skype videoconferencing to deliver the Lee Silverman Voice Treatment (LSVT) to participants with voice disorders due to Parkinson’s disease.14 Web-based sessions were conducted using broadband Internet videoconference and the participant’s home PC, Web camera, and headset with microphone. Supplementing the videoconference sessions was a weekly FTF session conducted in the participant’s home to objectively measure sound pressure (loudness), establish a therapeutic relationship, and to review home practice materials.14 Recordings collected during FTF and Skype sessions, using HotRecorder (www.hotrecorder.com), were forwarded to participants using e-mail for guided practice. A custom PC-based telehealth system developed at the University of Queensland achieved remote standardized and informal assessment5 and treatment6,7 of speech and voice disorders associated with Parkinson’s disease. The PC-based telehealth equipment and software capabilities used in the voice literature5–7 were similar with those used for studies of childhood speech and language disorders.26–28 Customized software supported videoconferencing (320 · 240 pixel resolution),5,7 electronic data sharing, and the SLP practitioner’s remote control of the Web camera. Additional features enabling remote delivery of services for voice disorders included (a) the ability to capture high-quality video (640 · 480 pixel resolution)5–7 and audio recordings (384 Kbps)5–7 separate from videoconferencing, (b) review of synchronous files as needed, and (c) viewable samples of real-time calibrated average measures of loudness, pitch, and duration data via an acoustic speech processor. Participants were not required to interact with the software as all features were either automatic or SLP practitioner directed.5,7
FLUENCY The use of low-tech telehealth technology such as plain old telephone service and postal service mail, has previously been used to deliver fluency interventions to adults and children.35,36 In a Phase I
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NEUROGENIC COMMUNICATION DISORDERS Neurogenic communication disorders are the result of brain insult or disease processes and can affect language (aphasia) understanding
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and formation, speech production (dysarthria and apraxia), and cognitive functions. Differential diagnosis of neurogenic communication disorders is crucial for appropriate management; therefore, telehealth methods have incorporated flexibility and usability of technology. Valid and reliable standardized and informal assessment of dysarthria,11 aphasia,13,21 and apraxia of speech12 were demonstrated using a custom PC-based telehealth system developed at the University of Queensland.5–7,26–28 The system’s software enabled videoconferencing over 128 Kbps supplemented with asynchronous audio and video.11–13,21 Electronic data sharing permitted display of instructional images and video clips11–13,21 and touch responses.12,13,21 The SLP practitioner controlled recording of high-resolution highquality video footage and audio files independent of the videoconference, as well as remote camera positioning. Participants were not required to interact with the software.11–13,21 Less sophisticated technology was shown to be effective for assessment of discourse ability in adults with posttraumatic brain injury.22 Although equipment and connectivity varied between two settings (Table 1), assessments were conducted using videoconferencing software (i.e., iChat) and hardware (e.g., Polycom 7000s) over high-speed Internet (512 Kbps or maximum of 900 Kbps) connectivity. Videoconferencing occurred over both platform-specific equipment and computers. No differences in video or audio quality or transmission speed between the two settings’ telehealth systems were reported.22 A facilitator was present with the participants to monitor safety and equipment, in addition to assisting with task materials. Telehealth has also enabled efficient,19 intensive,9,15,37 and individualized9,15,37 management of neurogenic communication disorders. A case study examined the use of Skype to deliver a portion of SLP services to an adult with severe apraxia of speech.15 Videoconferencing was conducted using PCs, headsets, and recorded using Call Recorder software (www.ecamm.com/mac/callrecorder/). Recordings were used to assess progress, and telehealth was supplemented with FTF sessions. Similarly, researchers at the University of North Carolina at Chapel Hill have demonstrated the feasibility of using Skype videoconferencing for a portion of therapy sessions aimed to deliver a modified script training intervention to adults with aphasia. This study also used asynchronous independent home practice using the participant’s PC or mobile phone.9 Soldiers with mild traumatic brain injury who were previously noncompliant with traditional therapy were shown to be adherent to cognitive rehabilitation therapy using videophone (used plain old telephone service) intervention combined with self-guided Webbased learning modules.19 Modules were accessed via computer and included didactic video clips, cognitive strategies, and homework. People with aphasia used virtual therapist software to complete a structured language intervention in their home setting both asynchronously and synchronously when an SLP practitioner monitored in real-time.37 The virtual software was accessed via the SLP practitioner’s and participant’s computers through the Internet. Software features included the option of real-time communication, customization, and store-and-forward progress monitoring.37 Family mem-
bers or caregivers underwent training to provide technology support for participants.
DYSPHAGIA Swallowing difficulties (dysphagia) can cause serious health complications such as malnutrition, aspiration, and potentially death.38 SLP practitioners’ interventions have been shown to improve swallowing safety, thus reducing the length of hospital stays and decreasing expenses related to pneumonia and other pulmonary complications.38 Dysphagia assessments can use both instrumental and clinical examination. Concurrent with FTF standards, remote assessment requires evaluation of oral and laryngeal structure/ function and trials with varying consistencies of food and liquid. The current telehealth infrastructure limits the type of procedures that can be accomplished remotely; therefore, studies have investigated balancing technology with facilitators.20,25 Limited availability of adequately trained SLP practitioners in instrumental swallowing assessments is a global concern. Real-time transmission of videofluoroscopic swallowing studies (VFSS) was achieved using PC-based videoconference hardware over broadband Internet.17,18 Communication between the fluoroscopy suite and the remote SLP practitioner was conducted using a speaker telephone. Store-and-forward technology enabled repeated viewing of the VFSS images and was controlled by the remote SLP practitioner.17,18 In an international pilot study, VFSS were performed and recorded by less experienced practitioners in Athens, Greece and then uploaded to a Web site for an expert SLP practitioner’s consultation at Columbia University in the United States. A virtually lossless compression codec was used to maintain video fidelity. The expert SLP practitioner retrieved the information via the Web site 1 day after the evaluation was conducted in Greece.16 Clinical swallowing evaluations were effectively administered using a custom videoconferencing system with facilitator assistance.20,25 The telehealth system was composed of two notebook computers equipped with custom videoconferencing software using high-quality audio and video compression technology over a 128-Kbps bandwidth and storeand-forward technology.20,25 The participant’s system was portable and required no technological interaction. Web cameras allowed concurrent visualization of the participant and the SLP practitioner. The participant’s Web camera was freestanding on an adjustable mobile platform and enabled remote control and zoom by the SLP practitioner. Split-screen imaging allowed concurrent viewing of the participant and SLP practitioner. Communication occurred through a free-field combined echo-cancelling microphone and Web conference speaker.20,25 The participant’s voice quality was captured and recorded using a lapel microphone. A finger pulse oximeter was used to measure the participant’s oxygen saturation throughout the assessment. The facilitator’s role was to perform tasks under the SLP practitioner’s direction, to evaluate and relay haptic and/or missed information to the SLP professional, and to adjust the equipment as necessary.20,25 Similar technology was used for swallowing and communication evaluations with head and neck cancer1 and post-laryngectomy24 patients. Mobile telehealth systems enabled videoconferencing over a
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3.5-Mbps 3G wireless phone network24 and 1 Mbps.1 External cameras captured high-quality video and still images. Hand-held medical cameras (Flexi dock 200; Inline Medical and Dental Pty., Sydney, Australia) with general imaging and intraoral probes were also used for close examination of the stoma and oral cavity.1 Split-screen imaging allowed simultaneous viewing of the participant and the SLP practitioner.1,24 Additional lighting sources enhanced visualization of examined structures.1,24 The technology was either remotely controlled or operated by the SLP practitioner.1,24 Store-and-forward technology enabled consultation with specialists.1
Discussion TECHNOLOGY CHALLENGES Advanced technology has limitations in the application of telehealth. Mashima and Doarn39 highlighted the importance of selecting connectivity mediums, bandwidth, and equipment based on desired clinical outcomes. Low bandwidth, network congestion, latency, low frame rate, and pixilation, reportedly caused occasional variability in audio and video quality and/or delays between audio and visual images during videoconferencing.5–7,9,11–14,20,21,24–28 Fluctuations in connectivity minimally resulted in session disconnection.21,24,37 Other drawbacks like audio static and echo,5,26 equipment malfunctions,1,6,24,37 reliance on the participant’s technology,3,14 and participant’s limited technology experience14 were described. Technological adversities were not reported to result in the practitioner’s or the individual’s discontinuation of telehealth services. Audio and visual disturbances were primarily associated with videoconferencing. Supplemental asynchronous technology was widely reported as a solution to real-time instabilities.5–7,11–13,20,21,25–28
FUTURE DIRECTIONS Although access to technology is rapidly expanding, digital prosperity is not equally distributed. Demographics can be determinative; for instance, individuals from low-income households and rural areas are less likely to own a computer and implement broadband connectivity.29 Smartphone ownership continues to rise,29 and mobile health is emerging as an effective medium for connecting individuals with healthcare professionals and enabling management of their own care.40 Future research should consider the viability of using mobile health not only to expand SLP services to individuals lacking the current telehealth infrastructure, but also to enable intervention in the context of everyday life events. Development of technical standards and guidelines is critical for appropriate and effective implementation of telehealth.39,41 Further research investigating the fidelity of equipment specifications and positioning, telehealth candidacy, and environment characteristics is warranted to assist in the development of professional standards. Moreover, inclusion of cost–benefit analyses is needed to justify telehealth reimbursement.
Conclusions The application of technology in SLP is growing. Evidence supporting the technical feasibility of telehealth to deliver SLP services
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has been demonstrated.1–28 SLP practitioners engaged in telehealth activities are responsible for providing the same quality of services via telehealth as they would be FTF.31 The infrastructure of telehealth is a significant component of telehealth models of delivery. Therefore, it is essential that SLP practitioners be educated on the successful implementation of technology, challenges that have been encountered, and future applications.
Acknowledgments The authors would like to thank Dr. Lisa Kelchner and Dr. Nancy Creaghead for their assistance and support.
Disclosure Statement No competing financial interests exist.
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16. Malandraki GA, Markaki V, Georgopoulos VC, et al. An international pilot study of asynchronous teleconsultation for oropharyngeal dysphagia. J Telemed Telecare 2013;19:75–79. 17. Malandraki GA, McCullough G, He X, et al. Teledynamic evaluation of oropharyngeal swallowing. J Speech Lang Hear Res 2011;54;1497–1505.
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32. Brennan D, Tindall L, Brown J, et al. A blueprint for telerehabilitation guidelines. American Telemedicine Association. Available at www.americantelemed.org/ docs/default-source/standards/a-blueprint-for-telerehabilitation-guidelines .pdf?sfvrsn = 4 (last accessed August 9, 2013). 33. Janota J. 2012 schools survey. American Speech-Language-Hearing Association. 2012. Available at www.asha.org/uploadedFiles/Schools-2012-SLPWorkforce.pdf#search = %22school%22 (last accessed August 9, 2013). 34. Furr MC, Larkin E, Blakely R, et al. Extending multidisciplinary management of cleft palate to the developing world. J Oral Maxillofac Surg 2011;69:237–241. 35. Lewis C, Packman A, Onslow M, et al. A Phase II Trial of telehealth delivery of the Lidcombe Program of Early Stuttering. Am J Speech Lang Pathol 2008;17:139–149. 36. Carey B, O’Brian S, Onslow M, et al. Randomized controlled non-inferiority trial of a telehealth treatment for chronic stuttering: The Camperdown Program. Int J Lang Comm Dis 2010;45:108–120. 37. Cherney LR, Kaye RC, Hitch RS. The best of both worlds: Combining synchronous and asynchronous telepractice in the treatment of aphasia. Perspect Neurophysiol Neurogen Speech Lang Disord 2011;21:83–93. 38. Ashford JR, Logemann JA, McCullough G. Treatment efficacy summary. American Speech-Language-Hearing Association. Available at www.asha.org/ uploadedFiles/public/TESDysphagiainAdults.pdf#search = %22dysphagia%22 (last accessed August 11, 2013). 39. Mashima PA, Doarn CR. Overview of telehealth activities in speech-language pathology. Telemed J E Health 2008;14:1101–1117. 40. Poropatich R, Lai E, McVeigh F, et al. The U.S. army telemedicine and m-health program: Making a difference at home and abroad. Telemed J E Health 2013;19:380–385. 41. Mashima PA, Brown J. Remote management of voice and swallowing disorders. Otolaryngol Clin North Am 2011;44:1305–316.
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Address correspondence to: Casey Stewart Keck, MA Department of Communication Sciences and Disorders College of Allied Health University of Cincinnati 3202 Eden Avenue Cincinnati, OH 45267
30. Reynolds AL, Vick JL, Haak NJ. Telehealth applications in speech-language pathology: A modified narrative review. J Telemed Telecare 2009;15:310–316.
E-mail: [email protected]
28. Waite MC, Theodoros DG, Russell TG, Cahill LM. Assessing children’s speech intelligibility and oral structures and functions via an Internet-based telehealth system. J Telemed Telecare 2012;18:198–203.
31. American Speech-Language-Hearing Association. Professional issues in telepractice for speech-language pathologist. 2010. Available at www.asha.org.policy/PI2010-00315.htm (last accessed June 21, 2013).
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Received: September 3, 2013 Accepted: October 15, 2013
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