Increasing Pediatric Audiology Services via Telehealth

Abstract

Telehealth as a means to deliver health care services has been used by physicians for many years, but the use of telehealth in audiology, specifically in pediatrics, has been minimal. Barriers such as licensure, reimbursement, technology, and equipment have been cited as reasons for audiologists not participating in telehealth. However, the COVID-19 pandemic created the need for telehealth services to be widely used to safely increase access to healthcare, and emergent orders helped reduce previous barriers so that audiologists could participate in telehealth service delivery. This article details three cases where audiologists delivered telehealth services to children. These case studies demonstrate portions of the Division of Audiology Telehealth Program of the Cincinnati Children's Hospital Medical Center and how they increased access to hearing healthcare in response to the COVID-19 pandemic.

The COVID-19 pandemic has resulted in periodic clinic shutdowns as well as provider and patient restrictions that have limited access to health and hearing care for persons across the country. In some situations, patients are not seeking healthcare services due to concerns with COVID-19. The Centers for Disease Control and Prevention reported that 4 out of 10 adults were and may continue to be delaying healthcare due to fears associated with COVID-19. ¹ These same concerns extend to patients who need pediatric audiology services.

At Cincinnati Children's Hospital Medical Center (CCHMC), more than 1,300 patient appointments in the Division of Audiology had to be cancelled and rescheduled due to COVID-related shutdowns between March and May 2020. Of those, approximately 37% had appointments related to hearing devices or auditory processing evaluations. The remaining were routine hearing tests, assessments following failed newborn screenings, or vestibular/balance evaluations. As the clinics reopened, initial challenges to providing needed hearing care involved self-imposed restrictions on patient volumes and reduced staff capacity due to social distancing guidelines. These challenges combined with patients and families potentially delaying healthcare due to fears associated with the pandemic created problems with access to needed care.

One of the solutions to providing care during this time was using telehealth to deliver applicable audiology services. CCHMC has a dedicated center for telehealth that provides support across the hospital. In May 2020, CCHMC had requested that all outpatient divisions use telehealth to increase access to care with a goal of evaluating and treating one-third of their patient populations via telehealth. Audiology is typically a procedural heavy discipline where the belief exists that providing optimal care can only be accomplished with a sound booth, dedicated equipment, and the ability to connect directly to hearing devices. This perspective can be compounded when the patient's developmental age and overall ability to complete or cooperate for a scheduled appointment or procedure is added to the formula.

Between 2014 and 2016, the Division of Audiology had trialed several pilot programs using synchronous video telehealth platforms, but their success was limited by factors such as provider buy-in, reimbursement, licensure, scheduling logistics, video platforms, and inability to connect to hearing devices remotely. ² At the time, the trials were primarily consultative in nature and focused on hearing aid evaluations, delivery of test results, and hearing aid repairs. Fast-forward to March 2020 and the emergency situation created by the pandemic produced the necessary stimulus to use telehealth technologies to try to reach our families to provide audiologic care. Fortunately, many of the previous barriers to concerted use of telehealth had been addressed and/or improved during the 4-year gap. The emergent orders established by both the federal and state government provided relief to barriers associated with licensure and marginal improvements in reimbursement for audiology services. For example, in April 2020 the Centers for Medicare and Medicaid Services (CMS) expanded the list of Medicare eligible telehealth providers to include audiologists and speech pathologists for the duration of the public health emergency, but reimbursable services were limited to four cochlear implant codes ( CMS Expands List of Medicare Eligible Telehealth Providers to Include Audiologists | Audiology ). Legislative efforts are ongoing to expand telehealth benefits permanently for Medicare beneficiaries beyond the public health emergency period. This is important for pediatric audiologists due to the ramifications that Medicare laws may have on recognition and expanded payment for services to those who have Medicaid and commercial or private insurance plans.

Prior to the pandemic, virtual platforms to deliver telehealth services were limited due to HIPAA compliancy, connected infrastructure, and available features such audio and file sharing. Our initial telehealth program used Cisco Jabber, but a recent switch was made to Microsoft Teams as the platform of choice, which was the system that was used to complete the following case studies. These case studies highlight how we are using synchronous video-telehealth, via Microsoft Teams and EPIC electronic medical records, to provide hearing aid and auditory processing evaluation services for the pediatric population. The providers in the following case studies were located at the hospital and the patients and their families were located at their home residences. The cases presented here do not demonstrate procedures that result in increased payments from third parties. Indeed, many of the procedures presented in these cases are not often paid for by third parties irrespective of where the services are performed.

Hearing Aid Evaluation Via Telehealth

A 17-year-old female presented immediately following an ear, nose, and throat (ENT) physician appointment due to patient reports of decreased hearing. She had been previously diagnosed with mild conductive hearing loss for the right ear only. On this day she was seeking otologic treatment due to decreased hearing on the left side with a perception of sound she described as a hollow barrel. Type A tympanograms were obtained bilaterally which was consistent with testing completed 6 months prior. However, air conduction and bone conduction pure tone testing revealed a moderate rising sensorineural hearing loss for each ear which indicated a significant change in hearing for both ears.

Following her hearing test and subsequent counseling, it was determined that this patient was an appropriate candidate for binaural amplification. She and her mother were interested in moving forward with obtaining hearing aids. This patient had a significant family history of hearing loss with both her mother and maternal grandmother; so, they were comfortable with, and knowledgeable about, hearing aids. Due to their experience with amplification, the parents were agreeable to a telehealth hearing aid evaluation via Microsoft Teams.

Although the audiologists and family were comfortable with a hearing aid evaluation via telehealth, there were several steps in the process that were completed prior to the encounter. Immediately following the patient's hearing test, a real ear to coupler difference value was obtained for each ear so that individual characteristics could be applied to hearing aid verification. Earmold impressions were taken for each ear without incident and each ear was measured to determine receiver wire length. Since we were able to complete all of the procedures that required the patient to be on-site at the diagnostic assessment, it allowed for the remainder of the hearing aid evaluation to be completed over telehealth.

Approximately 2 weeks later, this patient was seen for a hearing aid evaluation via telehealth using Microsoft Teams via Video Connect within the EPIC electronic medical records system. The patient and her mother were both present for the appointment. The appointment began by discussing her communication needs and current situations in which she was experiencing hearing difficulty. Various hearing aid technologies and styles were discussed, and they were shown a demonstration of hearing aids via the web camera and sharing of the provider screen. The remainder of the telehealth appointment was spent discussing the hearing aid fitting process, expectations about hearing aids, and insurance information.

One month later, she was successfully fit with binaural hearing aids and she is currently wearing her hearing aids full time. She is benefitting from the hearing aids in school and at work. She also utilizes her remote microphone in a variety of communication environments.

This patient was seen in May 2020 when CCHMC had just started the recovery process from the state-mandated COVID-19 stay-at-home orders. Social distancing requirements remained in place and minimizing face-to-face contact with patients was encouraged. In this situation, telehealth was valuable because it significantly reduced the amount of time the patient and provider were required to be face-to-face in a closed environment without sacrificing important components of the hearing aid evaluation process. It also reduced the number of trips that this family had to make to the hospital because they were able to see ENT, get an updated hearing test, and acquire earmold impressions in one visit when that would have previously required two or three separate appointments. This case exemplifies a realistic and simplistic way to incorporate telehealth into audiology practice without sacrificing critical components of the hearing aid process that require the patient to be physically present.

Hearing Aid Validation via Telehealth

At CCHMC, the standard follow-up procedures for patients recently fit with hearing devices is to have a hearing aid check appointment scheduled approximately 1 month post fitting to complete validation measures. The specific validation measures at this appointment are variable depending on the age of the patient but typically encompass subjective or qualitative assessments and objective speech testing in the sound booth. This case study demonstrates how Microsoft Teams and remote device programming were creatively used to deliver validation measures and fine tuning of hearing aids. The Division of Audiology created a PowerPoint presentation with embedded audio files that could be presented to the patient using telehealth via Microsoft Teams. The audio files include access to the following speech audiometry tests at two different presentation levels (average and soft): Central Institute for the Deaf (CID) W-22, Northwestern University (NU)-6 Auditory Test, the Phonetically Balanced Kindergarten word list (PBK), The Word Intelligibility by Picture Identification (WIPI) Test, the Ling-6 (HL) Test, and the Bamford-Kowal-Bench Speech-in-Noise (BKB-SIN) test. Each audio file has a calibration tone; so, the patient can adjust their speakers/volume to a most comfortable listening level prior to testing via telehealth.

The patient was a 16-year-old male with known bilateral asymmetrical sensorineural hearing loss due to meningitis. He is considered an experienced hearing aid user as he has had amplification since he was a toddler. His pure tone average is 88 dB HL in the right ear and greater than 110 in his left ear (see Fig. 1 ).

Figure 1.

Hearing aid validation patient audiogram.

He is considered an aural/oral communicator, although it is important to note that this patient's speech articulation is poor. He was previously implanted in the left ear at 4 years old. He never adjusted well to his cochlear implant despite aural (re)habilitation therapy and preferred conventional hearing devices. Most recently, a decision was made to switch from traditional behind-the-ear (BTE) hearing aids to receiver-in-the-ear (RITE) hearing aids. He was fit with a RITE aid for the right ear using a power receiver encased in an acrylic mold and a CROS transmitter for the left ear. His hearing aid was programmed and verified to DSL targets with frequency lowering technology activated. At the fitting, he was pleased with the sound quality other than it sounded quieter than his previous BTE aid.

This patient was offered a telehealth appointment to complete his follow-up services and he accepted. Both the patient and his mother were provided instructions on what would be accomplished during the telehealth appointment with regard to hearing aid adjustments and aided testing. The patient also was provided with instructions on downloading the hearing aid vendor smart application for remote device support in anticipation that some adjustment might be needed during the telehealth visit.

On the day of the telehealth appointment, we were able to connect with the patient using Microsoft Teams via the Video Connect feature in EPIC without incident. At CCHMC, the patient receives an automated link sent to their e-mail 24 hours prior to their scheduled telehealth appointment. Upon selecting the link, they are prompted to download or connect to Microsoft Teams. The patient was using his Apple iPhone to connect to the appointment and we were using a PC with a Logitech Web-Cam and headset.

Once connected, we conducted our Hearing Aid Intake Questionnaire to determine hearing aid usage, identify any concerns or problems, and address barriers to managing his hearing health care. The patient reported that he was using the hearing aids all waking hours and had no significant complaints other than the request to increase the volume for his right aid (primary device). At that time, we put the Microsoft Teams call on-hold and connected to his right aid via the hearing aid vendor remote device support smart application. Within this remote device application, the patient is able to see and hear the provider through the application and the hearing aid. The hearing aid's overall gain for soft and average inputs was increased along with increasing the acclimatization level to account for the patient's request for increased loudness. The patient acknowledged a big difference and was happy with the changes made to the programming. The changes were saved to the device via the smart application and then the encounter was switched back to Microsoft Teams to complete the validation testing.

The second part of the appointment was dedicated to aided/validation testing. As mentioned earlier, this patient has poor speech articulation and the decision was made to use the Ling 6 (HL) Test to determine his acoustic access with his new devices. When ready to start testing, the audiologist ensured the patient was in a quiet room and instructed him that he will see a PowerPoint presentation on his device as well as hearing words or sounds that he will be asked to repeat.

The Ling 6 was administered at the average and soft levels to simulate various inputs and was scored using detection and identification labels. The patient's scores from this appointment and prior testing are shown in Fig. 2 .

Figure 2.

Hearing aid validation scores using the Ling 6 sound test for the telehealth encounter and a prior encounter using the sound booth.

After completion of the testing, we were able to validate that his recent hearing aid fitting was providing him adequate acoustic access and that this frequency lowering feature was not causing confusion between /s/ and /sh/ speech sounds. His aided Ling 6 testing during this appointment was comparable to that completed in the sound booth at a prior appointment. After completing the Ling 6 testing, the remaining portion of the telehealth appointment provided education about connectivity. The decision was made to follow up with the patient in 1 year for an updated audiogram and hearing aid check, or sooner if concerns arise.

This case study demonstrates how the use of telehealth, PowerPoint, Microsoft Teams, and remote device programming can help provide audiologic care to patients. It is understood that the test results in a virtual setting cannot be directly compared with those obtained in the sound booth. In this case, it was not our intent to identify progress on the development of auditory skills. Rather, our goal was to reduce the need for return visits by the patient to mitigate the potential for the spread of COVID-19. We were able to use the test results, however, alongside qualitative assessments, to determine if (1) the patient had access to sound and (2) if further validation testing and/or program adjustments were indicated. In this particular situation, we were able to address the patient's request for hearing aid adjustment as well as determine that his hearing aids were providing consistent benefit without requiring another face-to-face appointment. The patient and his mother were satisfied with the outcome and appreciative of the opportunity to complete the appointment remotely, versus in person, citing transportation difficulties and the patient not having to miss school. In addition, the telehealth appointment took 30 minutes to complete, whereas our in-person appointments are generally scheduled in 1-hour increments. Thus, this case study demonstrates not only an efficiency of using telehealth but also opportunities to increase provider productivity through increasing access by reserving face-to-face appointment slots for those who truly need an in-person appointment.

Auditory Processing Evaluations via Telehealth

Due to COVID-19, our outpatient clinics were shut down for nearly 6 weeks with the exception of what was deemed emergency appointments. For the audiology service, emergent appointments included children without sound due to broken or nonfunctioning equipment or concerns for significant changes in hearing sensitivity. Auditory processing or listening problems were not classified as an emergency concern. When the clinic recovered to normal operating status, we had a high volume of patients waiting for auditory processing evaluations.

Even with resumed operations, there were strict restrictions on the amount of time that could be spent in the testing booth. This made it nearly impossible to complete any form of auditory processing testing with the exception of brief screening measures. Parents became increasingly concerned about their child's listening skills and the fast-approaching school year, plus the uncertainty of in-person versus virtual instruction. Our division wanted to support these families to the extent possible and made the determination to incorporate telehealth practices into the assessment process.

Irrespective of COVID-19, our division has attempted to change our intake process and criteria for auditory processing evaluations throughout the years, primarily due to the volume of inappropriate referrals for APD testing. The COVID-19 pandemic provided the opportunity for the Division of Audiology to rethink the intake and testing process in an attempt to minimize the number of inappropriate referrals. The revised process begins by sending an extensive case history form and an internally created neurodevelopmental questionnaire to the parents. The Auditory Neurodevelopmental Clinic (ANC) Questionnaire includes five questions (25 total) provided by experts from each of five disciplines at CCHMC: audiology, speech language pathology, developmental pediatrics, occupational therapy, and the reading literacy center. A copy of the ANC is available in the Appendix. The purpose of the questionnaire is to help guide the provider and family to determine which discipline would be the most appropriate to see the patient first. Children with suspected auditory processing disorders can have language disorders, intellectual disabilities, attention disorders, or reading concerns. The ANC questionnaire helps reduce the number of referrals for APD testing when the parent does not have concerns about the child's listening skills. The goal is to get families to the most appropriate evaluation and avoid unneeded evaluations if possible.

A 6.5-year-old female was referred for an auditory processing evaluation due to parent's perception of difficulty in following multistep instructions as well as general listening concerns. Due to COVID-19, the patient was scheduled for a telehealth auditory processing intake appointment. At the time of the appointment, the patient's mother was connected to one of the audiologists who specializes in auditory processing assessments. During the telehealth appointment, the mother reported a normal pregnancy followed by a normal birth. The patient passed her newborn hearing screening, there was no family history of permanent childhood hearing loss, and she did not have a history of recurrent ear infections. Early developmental milestones such as walking and talking were slightly delayed but still within normal limits. An electroencephalogram (EEG) was completed due to staring/seizure concerns approximately 7 months before the auditory processing telehealth appointment. The EEG was normal and neurology reported no seizure concerns. The patient reported headaches that occur approximately three times a week. Her mother reported that a neuropsychological evaluation was recommended, but she was told that the patient did not meet the criteria to complete testing. The patient was receiving private occupational therapy for fine motor concerns.

The ANC Questionnaire was completed during the telehealth appointment. The questionnaire revealed the most prominent areas of concern were speech and language development, reading, and developmental behavioral issues. Far fewer concerns were actually reported about auditory or sensory factors. Using the ANC results to further probe these areas, mother reported that her child is in kindergarten at a private school where both academic and reading concerns were reported. She is not on an IEP or 504 Plan at school but is receiving help from the intervention specialist in her regular classroom. Her mother indicated that reading skills are improving but still well behind her peers. The child struggles with phonological awareness and sounding out of words and her mother also was concerned about the patient's receptive and expressive language skills. She reported that the patient struggles to answer questions appropriately and express herself in concise manner. The primary auditory concern was listening and difficulty following multistep instructions.

The audiologist's initial impression was the patient would be better served to receive evaluations in other disciplines. Both a speech/language evaluation and a reading/literacy evaluation were recommended before considering an auditory processing evaluation. The reason for this was twofold. First, language and reading/literacy were the primary areas of parental concern and second, standardized auditory processing assessment materials are fairly limited for children younger than 7 years. Initially, it was recommended that the parent not schedule an auditory processing evaluation until the patient was 7 years of age. Additionally, the parent was counseled that our clinic does not diagnose a child with an auditory processing disorder at 7 years old but instead gives them the label of at-risk for an auditory processing disorder. Our clinic will provide recommendations to help children younger than 8 years with perceived listening difficulties or children who demonstrate behaviors consistent with an auditory processing disorder.

Based on the telehealth discussion with the parent, and the results of our questionnaire, the patient was scheduled for a face-to-face appointment to conduct a hearing test and to screen for an auditory processing disorder. The audiologic evaluation revealed that the patient had normal peripheral sensitivity and normal middle ear function. The patient passed both the dichotic listening and speech-in-noise screening tests. Her mother was counseled that auditory processing performance was age appropriate for the limited testing that could be completed. The formal speech-language evaluation and reading assessment were recommended and scheduled.

The entire process from intake to evaluation was a success for the patient and family. The telehealth appointment was extremely helpful to understand the reasons for referral. The telehealth appointment was important to the patient's care because the parent was able to express her significant level of concern and for her to gain perspective on other neurodevelopmental possibilities. In addition, the audiologist was able to counsel the parents on realistic expectations for the in-person auditory processing evaluation. The parent knew that the testing would be limited due to the patient's age and that the evaluation would not result in a formal diagnosis. The audiologist observed that the parent felt relieved after the in-person auditory processing screening. She was appreciative of the referrals to other disciplines and knowing that additional auditory processing testing could be completed when the patient was older.

In general, an auditory processing evaluation at our center takes about 3 hours. This includes time for the history, traditional audiologic assessment, and specific tests to evaluate auditory processing skills. In this case, the telehealth appointment lasted approximately 1 hour as did the face-to-face appointment. In total, our incorporation of telehealth into the auditory processing assessment process reduced our time commitment by one-third. Other benefits of an initial telehealth appointment included guiding the families to other disciplines in which they have greater concern, counseling families on children who are too young to complete standardized testing, and helping families understand what factors may preclude their child from testing such as poor speech articulation skills and intellectual disabilities.

Discussion

Prior to COVID-19, the Division of Audiology at Cincinnati Children's Hospital Medical Center was trying to find a niche for telehealth. Technological improvements combined with the local, state, and federal emergent responses to the pandemic have made finding that niche somewhat easier. Our profession is one that is procedural and equipment heavy. However, that does not mean that telehealth does not have application in pediatric audiology. These case studies highlight a portion of our program at CCHMC and help illustrate how efficient and effective telehealth platforms can be advantageous for both the patient and provider. What was paramount in providing services via telehealth was not only increasing access to care but ensuring the care that was provided thru telehealth had a predictable, purposeful, and commensurate outcome for the patient. Clinical research regarding outcomes need to be conducted, particularly when combined with continued technological enhancements, legislative efforts, and improvement in reimbursement, to continue the positive momentum that telehealth in pediatric audiology is experiencing. Other areas for telehealth development that may sustain growth in remote pediatric audiology services include an increased focus on how pediatric audiologists can provide treatment and diagnostic services in a hub and spoke model with a trained assistant at the spoke site, similar to how telehealth services are provided in the Veterans Affairs Healthcare system, as well as developing risk profiles and alternatives to accessing diagnostic information (Swaneopel et al 2020) for the pediatric population.

As of February 2021, the Division of Audiology has provided more than 200 telehealth appointments for hearing device and central auditory processing evaluation since March 2020. We have focused our telehealth goals into two areas: (1) to see an average of 20 patients per month via telehealth or (2) to have 10% of the total applicable populations evaluated via telehealth. Progress toward those goals can be seen in Fig. 3 .

Figure 3.

Cincinnati Children's Hospital Medical Center (CCHMC) audiology telehealth encounters for the 12 months ending February 2021.

Prior to the pandemic, our telehealth program was intermittent at best. Fig. 3 shows that our numbers have risen significantly to a mean of 19 patients per month since October 2020. These numbers are, in part, due to a positive upward trend in provider motivation and buy-in. Prior to the pandemic, we had three providers out of a staff of 32 clinical audiologists participate in telehealth services, and these were mostly for the pilot programs. Currently, we have 17 providers who are actively providing care through telehealth. When taking into account applicable populations and staff specialization, we have a total of 27 audiologists who could see patients who are eligible for telehealth. That represents 63% of our staff who have experience providing telehealth services and represents a greater than 90% increase in provider participation during the COVID-19 pandemic.

Most important is the perceived outcome and experience from the patient. All of our patients and parents receive patient family satisfaction surveys following their telehealth appointment. Questions on this survey are specific to their experience in our division and specific to telehealth. Thus far, families and patients are reporting a mean score of 4.44 (out of 5) satisfaction rate with our telehealth services. Fifty percent of those surveyed perceive the telehealth appointment to be shorter than in-person encounters. Furthermore, 78% reported that the audiologist was able to accomplish what was needed for the child's telehealth appointment and 70% reported they would consider future audiology visits via telehealth.

Conclusion

There have been some significant strides made in the delivery of telehealth in audiology including in the area of pediatric audiology, although the patient population presents unique challenges to remote services. The cases presented herein are examples of how telehealth can be integrated into clinical practice. The demand for such services will only be increasing from a patient's perspective. Unfortunately, the provider's desire may be not increasing at the same rate even when barriers have been lessened or removed. One of the positive impacts from the pandemic has been trialing innovative telehealth delivery of services to increase access to care that is safe, efficient, and results in good outcomes. As more outcome measures and tools become available, it is possible that some appointment types or services may be routinely offered as telehealth as a standard part of care in pediatric audiology. It is estimated that 95% of adults with hearing loss can be provided hearing care in low and no-touch models of care. ^{3 4} The question remains whether the same type of projection can be applied to pediatrics in the near future.

Appendix A.

Division of Audiology Telehealth Survey

You are being sent this survey because either you or your child recently had a telehealth appointment with the Division of Audiology at Cincinnati Children's Hospital Medical Center.

Our telehealth program is brand new and we are needing parental & patient feedback to learn from your experiences. The feedback you provide will help us to improve our program so we can better meet your needs.

This 11 question survey is confidential and should take less than 5 minutes to complete. If you have any concerns or questions about this survey please contact the Division of Audiology at 513-636-4236.

1. What is the age range of the child or patient that was recently seen for a telehealth visit in Audiology?

   • < 12 months

   • 1–3 years of age

   • 4–5 years of age

   • 6–10 years of age

   • 11–14 years of age

   • 15–18 years of age

   • > 18 years of age

2. What technology did you use to connect to the telehealth appointment?

   • Apple iPhone

   • Android Smart Phone

   • Apple iPad

   • Android Tablet or Kindle

   • Desktop Computer

   • Laptop Computer

   • Other

3. Which audio selection best matches how you connected to the telehealth visit?

   • Via internal/built-in speakers on device

   • Via external or connected speakers to device

   • Via wired headset s, ear buds, or headphones

   • Via wireless headsets, ear buds, or headphone

   • Other

4. What type of service(s) did you receive via telehealth?

   • Hearing Aid Evaluation

   • Hearing Aid Fitting

   • Hearing Aid Check

   • Hearing Aid Repair, Troubleshooting, and/or Programming

   • Earmold Cut & Fit

   • Central Auditory Processing Evaluation

   • General consultation and/or delivery of test results

   • Unknown

   • Other

5. Prior to this appointment please describe your experience level with telemedicine, including both you and your child.

   • Experienced (4 or more telehealth appointments)

   • Somewhat Experienced (1-3 telehealth appointments)

   • Inexperienced (first time completing telehealth appointment)

   • Other

6. How would you rate your satisfaction of the telehealth appointment in Audiology? (5 stars = very satisfied)

   • 5 Stars

   • 4 Stars

   • 3 Stars

   • 5 Stars

   • 1 Stars

7. In comparison to typical in-person appointments please select what best matches your experience in regards to length of appointment.

   • Telehealth appointment was significantly shorter than in-person appointments

   • Telehealth appointment was significantly longer than in-person appointments

   • There was no difference in length of telehealth appointment compared to in-person appointments

8. Do you believe the audiologist was able to accomplish what was needed for your child during the telehealth appointment?

   • Yes, all services needed for my child were able to be completed

   • No, some of the services needed for my child were not able to be completed

   • No, none of the services needed for my child were able to be completed

   • Other

9. Please select any problems you experienced during this telehealth appointment.

   • No problems

   • Problems with scheduling

   • Problems with downloading necessary links

   • Problems with connecting to audiologist

   • Poor video connection

   • Poor audio connection

   • Child would not cooperate for appointment

   • Hearing devices would not connect

   • Other

10. Would you consider telehealth again for future audiology visits, if possible?

    • Yes

    • Maybe

    • No

11. Please provide us any feedback that you believe will help to improve the telehealth services in audiology. We truly appreciate your time and your feedback. Thanks again for completing this survey.

Appendix B.

Appendix C.

Division of Audiology Telehealth Process Job Aid

(Updated 2/17/21)

Scheduling & Prior to Appointment

Audiologist

• 1. Screens chart & patient to determine if appointment can be accomplished remotely at your home or office without having patient in the office.

  1. Hearing Device Patients: If the patient is on-site for impressions, complete RECD

• 2. Discusses telehealth capabilities with patient/parent to determine interest level.

• 3. Communicates with audiology aide to schedule telehealth appointment. If appointment is to include remote device programming, then that should be communicated to the audiology aide as well.

Audiology Aide

If the telehealth appointment being requested is same day and/or less than 24 hours of notice, then the audiology aide is responsible for steps 4-7. Otherwise, a Center for Telehealth representative will be responsible for steps 6-7.

• 4. Schedules telehealth appointment in EPIC using either 24124 or 24420 appointment options for Follow-Up or New Visit.

  1. Verifies mailing address and e-mail address.

  2. If patient requires an interpreter, the Center for Telehealth should be contacted at telehealth@cchmc.org to arrange an interpreter.

• 5. If indicated by the audiologist, an email or MyChart Message may be sent to the parent with a request to obtain additional information on or prior to the appointment (i.e. remote device programming instructions, case-history forms, functional outcome measures, etc.)

  1. Hearing Device Appointment Intake Questionnaire

  2. Functional Outcome Measurements

  3. Remote Hearing Device Programming Resources

Center for Telehealth (Automated Process)

• 6. Creates Microsoft Teams link and sends required instructions & link to the patient via email one day prior to scheduled appointment.

  1. Patient receives email with Teams link, Teams instructions

  2. Patient also receives an additional link for audiology specific instructions within the Microsoft Teams link email. These instructions will only apply for those situations where remote device programming is needed. A copy of those instructions can be found here: Remote Device Programming Instructions/Letter .

• 7. Provider link for appointment is not sent as a calendar request or separate email. Instead, on the day of the appointment the provider will connect to the patient via Microsoft Teams by selecting the Video Connect button in EPIC. Please see Video Connect job aid for detailed instructions.

Day of Appointment

ASR/Center for Telehealth

• 1. Checks in & arrives patient.

Audiologist

• 1. Ensure you are in a private and secure room with as minimal visual and auditory distractions as possible.

  1. Please see provider preparation job aid by clicking here

• 2. Post a do not disturb notice on your door to alert other providers and patients that a telehealth appointment is in session.

• 3. Connect to patient via Microsoft Teams using the Video Connect instructions listed above.

  1. If patient does not show for appointment please skip ahead to step 10 below. (The provider should apply the same rules for waiting as they would for in-person appointments if the patient is late.)

  2. If patient is having difficulty connecting please have the patient/family contact the Center for Telehealth at 513-803-8353

  3. Remote Device Programming may be used in conjunction if needed and applicable.

  4. Request verbal consent from the patient about Telemedicine. Note, if they have a current (within 12 months) consent to treat that has telemedicine embedded in it, you still must request verbal consent.

  5. Ensure location of patient and complete verification of patient using two identifiers (i.e. last name and date of birth)

• 4. Complete appointment

  1. Go to Audiology Tab, Telemedicine

• 5. Complete documentation as typical.

  1. Telemedicine documentation is embedded in progress note/smartphrase (F2 to indicate provider location and patient location)

• 6. Complete communication management as typical.

• 7. Complete billing as typical for services rendered. There is no need to attach a telehealth modifier.

• 8. Complete follow-up as typical.

• 9. Sign Encounter, ignore Level of Service

• 10. If patient does not show for the scheduled telehealth appointment:

  1. Call Center for Telehealth at 513-803-8353 or

  2. E-mail telehealth@cchmc.org (include MRN, Department, provider and appointment time) notifying that patient did not show

  3. If any chart notes were made, provider should close encounter using Erroneous Error smartphrase.

Resources and Contacts:

• CCHMC Center for Telehealth

• 513-803-8353

• Telehealth Program Set-Up: Kathy.Kramer@cchmc.org

• Telehealth Training: Michelle.Rummel@cchmc.org

• Provider to Patient MyChart Instructions

• Division of Audiology Telehealth Lead: tommy.evans@cchmc.org