Audiology Telepractice in a Clinical Environment



Audiology Telepractice in a Clinical Environment
Annals of Otology, Rhinology & Laryngology I20(7):44l-447.
© 2011 Annals Publishing Company. All rights reserved.
Audiology Telepractice in a Clinical Environment:
A Communication Perspective
Ellen S. Crowell; Gregg D. Givens, PhD; Gloria L. Jones;
P. Bradley Brechtelsbauer, MD; Jianchu Yao, PhD
Access to adequate hearing health care is an obstacle that many individuals face worldwide. The prospect of providing
audiology services via the Internet is an attractive and viable alternative to traditional face-to-face interaction between
patients and audiologists, thus affording improved access to hearing health care for traditionally underserved populations. This article details our experience of using a web-based system with wireless audiometers and videoconferencing
software to administer remote audiological assessments in an active medical practice. It discusses the technological infrastructure used and the pragmatic issues that arise when the Internet, Bluetooth wireless audiometers, and videoconferencing devices are converged into a clinical setting. Patients at a local office of otolaryngologists were recruited to participate
in a study in which remote assessment results were compared to those collected from a traditional face-to-face assessment. Preliminary data demonstrated that the assessment results from the two sources were comparable. We conclude
that remote hearing assessment over the Internet can be achieved through a distributed system synthesized with Internet,
wireless communication, and videoconferencing technologies, supported by appropriate staff.
Key Words: audiology, otolaryngology, telemedicine.
Telemedicine is a form of health care that has
been in existence for decades,' yielding published
results in areas including, but not limited to, dermatology ,2 radiology,3 4 and psychiatry.^-^ More recently, telepractice has been applied to the diagnosis
and treatment of communication disorders.^"^ The
inability to effectively communicate with one's surroundings is a struggle that some individuals face on
a daily basis simply because they have limited or no
access to hearing health professionals. In audiology,
as in many other health professions, there is a gap
between those needing services and those providing
services. According to the World Health Organization, it was "estimated that in the year 2005 there
were 278 million people in the world with disabling
hearing impairment""'(P") and "a further 364 million people [were] estimated to have a mild hearing
loss."'0<P"' These staggering numbers provide a catalyst for the need to develop infrastructure and plans
to effectively assist these individuals with hearing
needs even when hearing health professionals cannot provide services face-to-face. As stated by the
American Speech-Language-Hearing Association,
the opportunity that telepractice can provide to these
individuals could open doors to the hearing world,
as well as ensure that "the quality of services delivered via telepractice [are] consistent with the quality
of services delivered face-to-face.""<P') Some areas
of research focusing on providing audiology services via telepractice include video-otoscopy,'2 auditory thresholds,'-^•''' hearing screenings,'-^ immittance measurements,'^ distortion product otoacoustic emissions (DPOAEs),'^-'^ auditory brain stem
response testing'9'20 (also Campbell and Hyde, unpublished observations), cochlear implant programming,'-2' and the administration of the Hearing in
Noise Test (HINT) .22
East Carolina University (ECU) has been developing and conducting research on telepractice in the
audiology field for many years and has continually
worked to develop better and more accessible systems. In 2003, Givens and Elangovan'-^ introduced a
system that was able to administer pure tone air and
bone conduction audiometry by remotely manipulating a standard audiometer via the Internet. Elangovan'"' described a similar study, also performed at
East Carolina University, that tested the feasibility
From the Department of Communication Sciences and Disorders. College of Allied Health Sciences (Crowell, Givens), East Carolina
University Telemedieine Center, Brody School of Medieine at East Carolina University (Jones), and the Department of Engineering,
College of Technology and Computer Science (Yao), East Carolina University, and Eastern Carolina ENT Head and Neck Surgery
(Brechtelsbauer), Greenville, North Carolina. Drs Givens and Yao, along with East Carolina University, have a provisional patent regarding the web-hased system described herein.
Correspondence: Gregg D. Givens, PhD, Dept of Communication Sciences and Disorders, College of Allied Health Sciences, East
Carolina University, Greenville, NC 27834.
Crowell et al, Audiology Telepractice in Clinical Environment
Web browsing/-
Telemedicine suite
of assessing DPOAEs by remotely manipulating a
computer that housed the required testing software.
Reportedly, these researchers collected comparative
data for both the pure tone audiometry results and
the DPOAE results on site and from a distant location.
More recently, a web-service based system that
could potentially support a subscription model was
developed at ECU through a partnership between
the Department of Communication Sciences and
Disorders and the Department of Engineering .^^
This web-based system was developed to serve as
the medium to conduct audiological assessments via
telepractice applications specifically through the use
of the Internet.
At present, an effort is ongoing to identify possible networking and operational issues in implementing the web-based service system in a clinical
setting, as well as documenting the feasibility and
reliability of such a system.
The discussion below relates to this ongoing effort
relative to technological infrastructure and pragmat-
Fig 1. Data exchange between audiologist and patient through web server.
office (Patient)
ic issues that were encountered with the networking
system, as well as preliminary results.
Description of Web-Based Audiology Telepractice System. A detailed description of the web-based
system can be found in previous publications.^-^-^"* In
brief, the central part of the remote hearing assessment system is a web server, which hosts all application-level programs, as well as the required database (Fig 1). The web server was implemented with
a three-tier architecture to improve software modularity and portability.2^^ Audiologists, who will be
operating the testing application, log in to the server with web browsers through their terminal computer to operate a remote audiometer. Currently, the
web server is set up as a virtual machine located in
the Science and Technology Building at ECU. The
server runs a virtual data-center operating system
ESX with 3.5 updates from VMware Inc. The virtual machine features dual 3.4 GHz central processing units and 2 GB RAM and is set up as a Windows
2003 Pro Virtual Server. For our system, the database is implemented on the same virtual machine as
the web server. For protection of the security of data
exchanged between the audiologist terminal and the
server, the server can only be accessed with SHTTP,
the Secure Hypertext Transfer Protocol; thus, necesTraffic
] |
( Satellite |
Otolciryngology office (Patient)
Telemedicine center (Audiologist)
Science Technology Building (Web server)
I 500m
Fig 2. Local map (Greenville, North Carolina, retrieved on October 21, 2009, from website of testing sites
and web server.
Crowell et al. Audiology Telepractice in Clinical Environment
Fig 3. Remote audiologist, located at
East Carolina University Telemedicine
Center, has views of web-based system
(far left), patient (center), and view seen
by facilitator at otolaryngology office
(far right).
sary data encryption is provided.
Testing Sites and Equipment Utilized. In our current study, two sites were used to assess the webbased system. The ECU Brody School of Medicine's
Telemedicine Center served as the remote site, and
a local otolaryngology office was the designated onsite location (Fig 2). By incorporating the traditional
telehealth practice of interactive videoconferencing
in use at the ECU Telemedicine Center, the remote
audiologist in this study was able to enhance the efficacy of the web-based system addressed herein.
a wireless Bluetooth-Ethernet gateway device. In
both cases, the on-site facilitator is only required to
power on the audiometer in order to provide remote
access by the audiologist.
The videoconferencing system setup for this location was slightly different from that of a normal telemedicine encounter (Fig 4). A VSX 3000 desktop
unit (Polycom, Pleasanton, California) with a video
camera (Canon USA, Inc, Lake Success, New York)
was connected as an alternate video source. The vid-
The remote audiologist was seated in a telemedicine room within ECU's telemedicine suite, which
was equipped with videoconferencing and Internet
capabilities as illustrated in Fig 3. The Polycom videoconferencing unit (Polycom Inc, Pleasanton, California) provided encrypted audio and video transmission between the two testing sites.
A local otolaryngology office served as the onsite, or patient, location and included a facilitator
(graduate student), an on-site audiologist, and a patient-participant. Equipment located at this site consisted of a Bluetooth-Ethernet gateway device (Parani 100, SENA Technologies, San, Jose, California), an OTOpod audiometer (Otovation LLC, King
of Prussia, Pennsylvania), and a Polycom videoconferencing unit. The Bluetooth-Ethernet gateway device and the videoconferencing system were both
connected to the Internet via the otolaryngology office. This connection had no use of a server, but instead went directly to the network. The router was a
Sonic Wall VPN (Virtual Private Network).
The OTOpod audiometer located on-site with the
patient is an off-the-shelf product that can exchange
data by use of Bluetooth telemetry, which can then
be connected to the Internet through a personal
computer (via EZURiO Bluetooth-USB adapter.
Laird Technologies, St Louis, Missouri) or through
Fig 4. Setup at testing site (otolaryngology office) with
remote audiologist having video communication from either video source 1 or video source 3 and audio communication from both video sources 1 and 3. 1 — videoconferencing desktop unit (video source 1); 2 — soundisolated booth; 3 — tripod camera (video source 2); 4
— door to sound-isolated booth; 5 — participant or patient; 6 — traditional audiometer; 7 — door to audiology
room; 8 — facilitator.
Crowell et al, Audiology Telepractice in Clinical Environment
250 Hz
6.43 ± 2.50
2.50 ± 2.58
500 Hz
2.86 ± 2.64
2.50 ±3.93
1,000 Hz
2.86 ±2.64
7.50 ±5.56
eo camera was mounted on a tripod located within
the sound-isolated booth in which the patient-participant was seated. The remote audiologist was able to
hear both the patient and the facilitator at all times.
However, only one video feed could be viewed at a
time. The remote audiologist was able to see the onsite facilitator or ask to be switched to the alternate
camera in order for all to view the participant. Once
the video source was switched, the audiologist was
able to view and hear the participant during the assessment, as well as continue to privately converse
with the on-site facilitator located outside the testing booth.
Current Status. By means of this system, participants were tested with a double-blind procedural
design. All individuals were adult patients (over 17
years of age) at the otolaryngology office and voluntarily consented to participate in the research study.
This study (#08-0700) was approved by the East
Carolina University Medical Center Institutional
Review Board, Each participant received a traditional face-to-face assessment of pure tone hearing
thresholds by an audiologist at the otolaryngology
office, as well as an identical assessment administered by a remote audiologist via telepractice. In this
double-blind design, the testers at each site were not
privy to the results collected at the other site. Eor
example, the audiologist located at the remote site
did not have prior knowledge of the thresholds determined on-site through traditional means.
Results collected at each testing site were compared for accuracy, and the test administration completion time for the telepractice portion was also reported. We are optimistic regarding the preliminary
results garnered thus far (see Table), This Table displays the mean difference (in decibels), as well as
the standard deviation, between the traditional and
telepractice assessments for all participants at each
accessed frequency. The mean differences between
the two assessments were all less than or equal to 10
dB hearing level, which is considered to be clinically
acceptable. The average amount of time required to
complete a hearing test via telepractice was approximately 7 minutes per test administration, consistent
with the time required for a traditional face-to-face
assessment. Participants are still being recruited to
determine any concerns, as well as to gather additional data from a larger sample.
2,000 Hz
5.71 ±3.91
1.67 ±2.44
4,000 Hz
4.29 ± 3.54
10.00 ±6.06
8,000 Hz
7.86 ±4.86
This novel web-based audiology telepractice system integrated web services with Bluetooth wireless telemetry and videoconferencing equipment.
Although the Bluetooth-Ethernet gateway and the
server have previously been studied,2"* two additional issues were investigated when the web-based system was integrated into a clinical environment: 1)
the simultaneous presence of the Bluetooth device
used in the audiology telepractice system with the
hearing aid programmers used in the otolaryngology office; and 2) the bandwidth demands among
the web-based system, the videoconferencing traffic, and the otolaryngology office's regular Internet
data transmission. This section discusses these issues and points out the necessities of a facilitator at
the patient site.
Co-presence of Bluetooth Devices. One problem
that was encountered during testing was interference of the Bluetooth-Ethernet gateway device used
to connect the audiometer to the Internet with the
otolaryngology office's Bluetooth hearing aid programmers. Most audiologists use wireless devices
to program hearing aids, which are an integral part
of many audiology practices. Ensuring no interference was crucial to the feasibility of incorporating
this system. The Bluetooth-Ethernet gateway device was reprogrammed to allow connections only
to those Bluetooth addresses owned by the OTOpod audiometer. Even though this solution resolved
the predicament, we were forced to sacrifice system
flexibility. Before an audiometer could be connected
to the Internet during the initial setup, its Bluetooth
address had to be preprogrammed in the BluetoothEthernet gateway device.
Video Communication. The current study described herein utilized a Polycom VSX3000 desktop
videoconferencing unit that was readily available to
the ECU researchers. All of the videoconferencing
units used were encrypted to maintain compliance
with the Health Insurance Portability and Accountability Act. These units are also UL 60601-compliant for use in patient care environments. Site connectivity for the videoconferencing unit was obtained through E C U ' S network to the public Internet
and then routed through the otolaryngology office's
local network. The bandwidth for the videoconferencing system was set at a minimum rate of 384 ki-
Crowell et al, Audiology Telepractice in Clinical Environment
lobits per second and required an Internet connection separate from the web-based testing application. This provided the remote audiologist with a
smoother, more natural view of the participant's facial and body movements.
The use of a hard-end point videoconferencing
system — the described Polycom unit or one similar
— is popular among many telemedicine operations,
because these systems are equipped with encryption
for the interactive video and audio transmissions.
The systems are also scalable to the infrastructure
available, but do require sufficient bandwidth to
provide clear audio and video transmissions. It is
suggested that if one is to consider providing audiology telepractice services, investing in a hard-«nd
point or freestanding video conferencing system
would be beneficial. On the other hand, there are
further options available, including free video and/
or audio conferencing software programs (soft end
points) and inexpensive computer cameras, "webcams," that can be used to provide visual and audio contact. Further research needs to be conducted regarding the reliability and feasibility of these
options. Nevertheless, one must make certain that
no matter the videoconferencing system and/or network connectivity chosen, it must provide sufficient
encryption and/or network safeguards to ensure satisfactory privacy and confidentiality of patient information and resulting outcomes.
Internet Infrastructure. This study was conducted at a well-established university telemedicine
suite and with a well-connected otolaryngology office. Although we did experience some instances
in which the video and/or audio feed was affected
by slow transmission and breaks in audio communication, this hindrance was transitory and resolved
quickly, thus not affecting our ability to test. To further examine possible issues due to the introduction
of the videoconferencing traffic, an experiment was
conducted whose results showed that the audiology
telepractice testing caused no concerns to regular Internet usage in the otolaryngology office for completion of typical office duties (eg, uploading and
downloading images, e-mail, etc).
Few published studies in the field of audiology
telepractice have been conducted in areas with potentially less-than-ideal infrastructure. Successful
examples include isolated communities in Alaska^^
and Canada (Campbell and Hyde, unpublished observations) , rural elementary schools,' ^ and a regional medical center.'^ One such example detailed how
certain infrastructure options were not optimal for
provision of services. Polovoy^^ described the audiology telepractice applications used in the isolated
communities of Alaska, including the use of satellite transmission to conduct teleconferencing sessions. Unfortunately, satellite transmission was not
deemed ideal, because it resulted in "real-time delay,
audio problems, and networking problems."^-^^P^^^
A dedicated landline is presumed to provide better
communication functionality.
Additional research pertaining to infrastructure
requirements for the provision of audiology telepractice is needed for many settings, including but
not limited to military bases and/or hospitals. Veterans Health Administration clinics and/or hospitals,
residential facilities, and prisons.
Facilitator. Our current study protocol made use
of an on-site facilitator. This individual, who in our
case was an audiology graduate student, was responsible for obtaining participant consent, equipment setup, providing instructions, and participant
management. The facilitator was also responsible
for collecting the results from the participant's traditional audiological assessment.
Even though audiological services are being provided from a distant location through technological
applications, it is still advisable that a facilitator be
on-site with the patient. The exact role and training
level of the facilitator is an area of continuing study,
but having trained personnel at the patient site is
recommended, particularly for patient management
and placement of diagnostic equipment, ie, correct
headphone placement. Krumm et al"' also stated
caution regarding the need for knowledgeable technical support personnel.
Economic Considerations. As with any new modifications to patient-directed care, economic considerations are paramount. There are concerns whether
adopting a system like that described in this article
will monetarily benefit a clinical practice. Many of
the costs incurred with the proposed remote hearing assessment will be no different from those of a
standard audiometric setup. Our study indicates that
the Internet transmission required by this system is
no more than what currently exists in most office
locations, especially if digital transmission of patient data is already in use. The required facilitator
can be an existing staff member or a nursing professional with certain training. These costs are minimal
compared to those of a licensed audiologist spending crucial patient contact hours traveling to remote
clinical locations. Instead, these trained professionals can spend this time at the primary office seeing
more patients via telemedicine techniques. This system can also be economically beneficial for satellite
offices of medical practitioners as a triage initiative,
in that audiologists may see patients in remote loca-
Crowell et al, Audiology Telepractice in Clinical Environment
tions via telemedicine and then make an educated
determination as to whether these patients would be
candidates for hearing aids, cochlear implants, or assistive listening devices and make the recommendation for further follow-up by patients at the audiologist's home office. This system will also reduce
travel time for the audiologist and potentially reduce
the need for transportation of individuals in remote
locations if no follow-up audiological care is currently needed. Thus, the audiologist's time and efforts are more efficiently utilized in providing care.
In addition, although the current model discussed
herein is not available on the market, communications with the company who holds the license for
this technology indicate that their plan is to charge a
minimal monthly subscription for this service.
sues encountered and addressed in this effort may
occur when similar systems are implemented. These
include the following.
Another economic benefit is patient transportation. Many patients in our communities are unable
to be transported to audiology centers because of
medical conditions or current economic status. By
use of telemedicine, the costs incurred by patients
can be minimized when initial care and follow-up
care can be provided in closer locations. This is particularly important for traditionally underserved rural regions in which hearing services might be obtained only after hundreds of miles of travel.
3. In a converged network environment, despite
the highly advanced technology, a facilitator can aid
in providing optimal services and make audiology
telepractice more efficient.
This report describes an ongoing effort to provide
remote hearing assessment in a clinical setting. Is-
1. Depending on the current Internet infrastructure of the potential sites, additional bandwidth and/
or services might be required to provide optimal audiology telepractice services.
2. Since some devices commonly used in medical practices utilize the same wireless protocol (eg,
Bluetooth connection), co-presence of wireless devices should be closely examined. It is crucial for
a wireless system to automatically identify the devices with which it should be associated to ensure
that no other devices are causing or being affected
by interference.
The implementation of telepractice applications
in audiology is a promising field, as demonstrated
by previous research and the study described herein. However, studies heretofore have only examined successes and issues when the local and remote
sites were located within close proximity. Euture research requires determination of the reliability and
feasibility of assessments when this web-based system is utilized in worldwide locations with varying
amounts of infrastructure and support.
Acknowledgments: The authors thank the personnel at both the local office of otolaryngologists and at the East Carolina University
Telemedicine Suite for their gracious assistance. The authors also thank Alyson Butler, AuD/PhD. student in the Department of Communication Sciences and Disorders at East Carolina University, for her assistance in data collection, as well as the staff at the College
of Technology and Computer Science for their assistance in maintaining the web server.
1. Franck K, Pengelly M, Zerfoss S. Telemedicine offers remote cochlear implant programming. Volta Voices 2006;13:169.
2. Burgiss SG, Julius CE, Watson HW, Haynes BK, Buonocore E, Smith GT. Telemedicine for dermatology care in rural
patients. Telemed J 1997;3:227-33.
3. Crowe BL, Hailey DM, de Silva M. Teleradiology at a children's hospital: a pilot study. J Telemed Telecare
4. Elkateeb A, Richardson P, Kawaja A, Rahme P. A Javabased teleradiology system to provide services over a heterogeneous network. Telemed J E Health 2001;7:233-40.
5. McLaren PM, Blunden J, Lipsedge ML, Summerfield
AB. Telepsychiatry in an inner-city community psychiatric service. J Telemed Telecare 1996;2:57-9.
6. Ruskin PE, Silver-Aylaian M, Kling MA, et al. Treatment outcomes in depression: comparison of remote treatment
through telepsychiatry to in-person treatment. Am J Psychiatry
7. KuUy D. Telehealth in speech pathology: applications to
the treatment of stuttering. J Telemed Telecare 20(X);6(suppl 2):
8. Theodoros D, Hill A, Russell T, Ward E, Wootton R. Assessing acquired language disorders in adults via the Internet.
Telemed J E Health 2008;14:552-9.
9. Waite MC. Cahill LM, Theodoros DG, Busuttin S, Russell TG. A pilot study of online assessment of childhood speech
disorders. J Telemed Telecare 2006;12(suppl 3):S92-S94.
10. World Health Organization. Primary ear and hearing care
training resource: advanced level. Geneva, Switzerland: World
Health Organization. 2006.
11. American Speech-Language-Hearing Association. Audiologists providing clinical services via telepractice: position statement. 2005. Accessed July 29, 2010.
12. Eikelboom RH, Mbao MN, Coates HL, Atlas MD, Gallop MA. Validation of tele-otology to diagnose ear disease in
children. Int J Pediatr Otorhinolaryngol 2005;69:739-44.
13. Givens GD, Elangovan S. Internet application to tele-audiology—"nothin' but net." Am J Audiol 2003;12:59-65.
Crowell et al, Audiology Telepractice in Clinical Environment
14. Choi JM, Lee HB, Park CS, Oh SH, Park KS. PC-based
tele-audiometry. Telemed J E Health 2007;13:501-8.
15. Lancaster P, Krumm M, Ribera J, Klieh R. Remote hearing screenings via telehealth in a niral elementary school. Am J
Audiol 2008;17:114-22.
16. Krumm M. Ribera J, Schmiedge J. Using a telehealth
medium for objective hearing testing: implications for supporting rural universal newborn hearing screening programs. Semin
17. Elangovan S. Telehearing and the Internet. Semin Hear
2005 ;26:19-25.
18. Krumm M, Ribera J, Klich R. Providing basic hearing
tests using remote computing technology. J Telemed Telecare
2007; 13:406-10.
19. Krumm M, Huffman T, Dick K, Klich R. Telemedicine
for audiology screening of infants. J Telemed Telecare 2008;
20. Towers AD, Pisa J, Froelich TM, Krumm M. The reliability of click-evoked and frequency-specific auditory brainstem response testing using telehealth technology. Semin Hear
21. Ramos A. Rodriguez C, Martinez-Beneyto P, et al. Use of
telemedicine in the remote programming of cochlear implants.
Acta Otolaryngol 2009; 129:533-40.
22. Ribera JE. Interjudge reliability and validation of telehealth applications of the Hearing in Noise Test. Semin Hear
23. Yao J, Givens GD, Wan Y. A web services-based distributed system with browser-client architecture to promote teleaudiology assessment. Telemed J E Health 2009; 15:777-82.
24. Yao J, Wan Y, Givens GD. Using web services to realize
remote hearing assessment. J Clin Monit Comput 2010;24:4150.
25. Polo voy C. Audiology telepractice overcomes inaccessibility. ASHA Leader 2008;13:20-2.
Copyright of Annals of Otology, Rhinology & Laryngology is the property of Annals Publishing Company and
its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.