Telepractice in Speech-Language Pathology: The Evidence, the Challenges, and the Future This article provides a review of the evidence base for telepractice in speech-language pathology, the challenges that exist, and the future directions for this field. It describes the benefits of telepractice for clients and their families and outlines the evidence currently available to support the validity and reliability of this ... Article
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Article  |   September 01, 2011
Telepractice in Speech-Language Pathology: The Evidence, the Challenges, and the Future
Author Affiliations & Notes
  • Deborah Theodoros
    School of Health and Rehabilitation Sciences, The University of QueenslandBrisbane, St. Lucia, QLD, Australia
Article Information
Speech, Voice & Prosodic Disorders / Voice Disorders / Swallowing, Dysphagia & Feeding Disorders / Telepractice & Computer-Based Approaches / Articles
Article   |   September 01, 2011
Telepractice in Speech-Language Pathology: The Evidence, the Challenges, and the Future
SIG 18 Perspectives on Telepractice, September 2011, Vol. 1, 10-21. doi:10.1044/tele1.1.10
SIG 18 Perspectives on Telepractice, September 2011, Vol. 1, 10-21. doi:10.1044/tele1.1.10

This article provides a review of the evidence base for telepractice in speech-language pathology, the challenges that exist, and the future directions for this field. It describes the benefits of telepractice for clients and their families and outlines the evidence currently available to support the validity and reliability of this mode of delivery in the management of adult neurogenic communication disorders (aphasia, dysarthria, apraxia of speech); voice disorders; stuttering; dysphagia; laryngectomy; and articulation, language, and literacy disorders in children. The challenges facing telepractice in speech-language pathology and the future directions for this field are discussed.

Telepractice is an emerging area of service delivery in speech-language pathology that is likely to become an integral part of mainstream practice in the future. In order to achieve this, it is imperative that the profession accelerates its program of research and clinical endeavor in this area.

Telepractice is defined as “the application of telecommunications technology to deliver professional services at a distance by linking clinician to client, or clinician to clinician for assessment, intervention, and/or consultation” (American Speech-Language-Hearing Association [ASHA], 2005, p. 1). The position statement outlined by ASHA heralded a new era in speech-language pathology (SLP) practice that must respond to the ever-increasing demand on SLP services in health and education, rapid advances in telecommunication technologies, and associated societal changes.
SLP practice primarily involves an auditory and visual interaction between a client and a clinician. As such, SLP services can be readily translated into an online or technology-based environment, provided auditory and visual signals can be adequately replicated and transmitted at a distance. Various platforms have been developed to support service delivery in telepractice, which fall under two broad headings: synchronous (in real-time) and asynchronous (offline). The types of technology used in telepractice research have included the plain old telephone service (POTS; Carey et al., 2010; Wilson, Onslow, & Lincoln, 2004), videophones (Tindall, Huebner, Stemple, & Kleinert, 2008), conventional videoconferencing (Myers, 2005), personal digital assistants (PDAs; Halpern, Matos, Ramig, Petska, & Spielman, 2005), computer-based programs (Thompson, Choy, Holland, & Cole, 2010), and customized multimedia videoconferencing systems (Constantinescu et al., 2010b; Georgeadis, Brennan, Barker, & Baron, 2004; Theodoros, Hill, Russell, Ward, & Wootton, 2008).
In contrast to our cognate disciplines in physical therapy and occupational therapy, where physical contact is a core feature of practice, the scope of telepractice for SLPs is broad and has the potential to provide valid and cost-effective services to clients with all forms of communication and swallowing disorders. The application of SLP practice at a distance was recognized more than two decades ago; however, the exponential increase in the development of telecommunications technologies in recent years has placed SLP telepractice at the forefront of development in alternate modes of service delivery in the allied health professions. Numerous innovations in this method of service delivery in SLP are yet to be realized.
Benefits
The impetus for the development of telepractice in SLP has been driven by the need to provide equitable and cost-effective access to all clients, regardless of geographical location, physical disability, or social and economic status. The access issues for adult and pediatric clients living in rural and remote areas, where there are inevitably fewer SLPs, are clear (Pickering et al., 1998) and remain a vexing issue for public health and education systems worldwide. Of equal concern, however, are clients residing in urban areas where access to services may also be difficult due to disability, mobility, and financial issues; restrictive work schedules; and family support needs.
Although access to SLP services was the primary driver in the evolution of telepractice, there is now considerable evidence to support the premise that this mode of service delivery may actually enhance the quality of care provided, and, ultimately, quality of life (McCue, Fairman, & Pramuka, 2010; Winters & Winters, 2004). Winters and Winters (2004) suggest that telepractice has the potential to optimize the timing, intensity, and sequencing of intervention, leading to the greatest functional outcome for the client. Indeed, telepractice has the capacity to support intensive neurorehabilitation regimens, based on increasing evidence of neural plasticity and brain reorganization following brain damage (Bach-y-Rita, 2000). Examples of this can be seen in the use of computer-based language therapy for aphasia (Cherney, Halper, Holland, & Cole, 2008) and the treatment of dysarthria in Parkinson's disease (PD) via the Internet (Constantinescu et al., 2011) and a computer-based program (Halpern, Matos, Ramig, Petska, & Spielman, 2005). Furthermore, the capacity to monitor communication and swallowing function in an adult or child from a distance enables the clinician to optimize the timing of intervention to avoid or reduce morbidity and functional limitation.
A further benefit is the capacity to deliver SLP services to the child or adult in his/her own environment (e.g., home, local community, school, or workplace). Strong evidence exists to support the fact that interventions delivered in the person's natural environment or specific context (e.g., workplace, school) are more effective than the same approaches delivered in the clinic (McCue et al., 2010). These positive effects have been seen in generalization of behavior, functional outcomes, and patient satisfaction and self-management in various conditions, including stroke (Legg & Langhorne, 2004; Von Koch, Wottrich, & Holmqvist, 1998) and severe brain injury (Ylvisaker, 2003). Furthermore, this approach to community-based intervention is endorsed by the World Health Organization (WHO) framework, which promotes a person's functioning within the context of their environment (2001).
Of the world's population, 28.7% now have access to the Internet (Internet world stats, n.d.), and this number is steadily increasing. The possibility of delivering SLP services via telepractice, directly into the everyday lives of clients, is conceivable. Critical to the uptake of telepractice in mainstream SLP services will be to demonstrate the feasibility, validity, reliability, and cost-benefits of this mode of service delivery.
Evidence
Research in telepractice in SLP spans more than two decades. Most of this research has been conducted within the health service domain, with limited evidence from the education sector (Theodoros, 2010). Client and/or clinician satisfaction has been investigated in approximately 25% of all studies and has been remarkably positive (Theodoros, 2010). It is clear, however, that a major area of research that has received limited attention is the cost-benefit analysis (Theodoros, 2010). The economic attributes of telepractice are critical to sustainability in today's health-care and educational systems. Economic analysis of any SLP service via telepractice involves examination of the benefits and/or costs to the client and/or family and to the provider. It requires detailed information regarding the costs of technology, facilities, personnel, time expended by the client/family members and service provider, and client and provider travel expenses, as well as the effects on quality of life (Krupinski et al., 2006; Muennig, 2002).
Telepractice research has encompassed the majority of communication disorders in adults and children, including adult neurogenic communication disorders, voice disorders, and stuttering; and articulation, language, and literacy disorders in children. Recent research provides evidence to support the use of telepractice in the management of dysphagia and patients following laryngectomy.
Adult Neurogenic Communication Disorders
In the area of adult neurogenic communication disorders, research has focused on the assessment and treatment of aphasia, dysarthria, and apraxia of speech. Seminal research in the online assessment of these disorders has come from researchers at the University of Queensland, Australia. In this research, over 40 participants with mild to moderate-severe dysarthria (Hill, Theodoros, Russell, & Ward, 2009a; Hill et al., 2006), 32 participants with mild to severe aphasia (Theodoros et al., 2008; Hill, Theodoros, Russell, Ward, & Wootton, 2009), and 11 participants with mild to severe apraxia of speech (Hill, Theodoros, Russell, & Ward, 2009b) were assessed in a laboratory setting using a custom-made PC-based multimedia videoconferencing system. These assessments were conducted simultaneously online and face-to-face (FTF). The telerehabilitation system used in these studies featured videoconferencing over 128 kbit/s Internet connection; store-and-forward capabilities, enabling the capture of high-resolution and high-quality audio and video footage independent of the videoconferencing; the capacity to display written, auditory, and videoed stimuli; control of web cameras at the participant end; and touch-screen facility to enable participant interaction as per FTF procedure (aphasia study only).
The findings from these studies included good strength of agreement between the online and FTF assessors for oromotor performance and perceptual ratings of speech for the participants with dysarthria, with high inter- and intra-rater reliability across all parameters (Hill et al., 2009a). No significant differences between test scores on the Apraxia Battery for Adults-2 (Dabul, 2000) were found for the online and FTF assessments. In addition, moderate to very good agreement was obtained for the online and FTF ratings of apraxia of speech (Hill et al., 2009b). Similarly, no significant differences were determined between the online and FTF test scores on the Boston Aphasia Examination, 3rd Edition (Goodglass, Kaplan, & Barresi, 2001), with moderate to good agreement for assessor ratings and good to very good intra- and inter-rater reliability for the majority of the online ratings (Theodoros et al., 2008). Across each of these studies, participant satisfaction with online assessment was notably high (<80%). Although these studies demonstrated solid evidence for the online assessment of these disorders, the researchers acknowledged that certain aspects of the online environment did make it more difficult, at times, to rate some assessment tasks. For example, the occasional audio and video breakup made it challenging to assess certain aspects of aphasia, such as naming and paraphasia, as well as apraxia of speech (Hill et al., 2009b; Hill, Theodoros, Russell, Ward, & Wootton, 2009; Theodoros et al., 2008). The researchers suggested that some individuals with severe apraxia of speech may need to be assessed FTF in order to identify key components of the speech disturbance. This decision, however, needs to be made on an individual basis (Hill et al., 2009b). Despite some technical difficulties, these studies demonstrated that overall, the assessment of dysarthria, apraxia of speech, and aphasia can be validly and reliably achieved.
Constantinescu et al. (2010b) simultaneously assessed the speech and voice of 61 people with PD online and FTF by using similar technology with an integrated acoustic analyzer to measure vocal sound pressure level (SPL) and frequency in real-time across the Internet. They found comparable agreement between the two assessment environments for the majority of perceptual and acoustic measures of voice, oromotor function, articulatory precision, and speech intelligibility. Furthermore, the intra- and inter-rater reliability of the assessors was found to be comparable in the online and FTF environments on all assessment tasks.
Similar laboratory studies have been conducted at the National Rehabilitation Hospital in Washington, DC, using custom-built PC-based telerehabilitation systems (Brennan, Georgeadis, Baron, & Barker, 2004; Georgeadis et al., 2004). One study involved the assessment of language comprehension and expression using story-retelling in 40 participants with acquired brain injury (traumatic brain injury, or TBI; and cerebrovascular accident, or CVA) and various diagnoses of dysarthria, aphasia, apraxia, and cognitive-communication impairment (Brennan et al., 2004; Georgeadis et al., 2004). The participants were assessed in the online and FTF environments on two separate occasions. The telerehabilitation system operated on a 10 Mbit/s Local Area Network videoconferencing connection and included the capacity to display printed materials remotely at the participant site and to audio record the sessions. The researchers found no significant differences in story-retelling performance between the FTF and online environments (Brennan et al., 2004; Georgeadis et al., 2004). Brennan et al. (2004) subsequently showed that no significant differences in performance were evident across assessment environments when participant factors such as age, gender, technology experience, and educational level were considered. When participant performance was evaluated in relation to the type of neurological impairment, it was found that the participants with CVA performed equally or better online than FTF. In contrast, the participants with TBI demonstrated worse performance online, although this difference was not statistically significant. Georgeadis et al. (2004) suggested that attention difficulties can potentially affect participant performance online. High participant satisfaction was also recorded during these studies, supporting the premise that patients are comfortable with this mode of service delivery (Brennan et al., 2004; Georgeadis et al., 2004). In a more recent study from this group, Palsbo (2007) evaluated the validity of assessing functional communication online in people post-CVA and found that high levels of agreement were achieved between online and FTF assessments.
Telepractice treatment studies involving adult neurogenic communication disorders have largely been confined to the management of hypokinetic dysarthria associated with PD and to the management of aphasia. Studies in the treatment of PD have investigated the feasibility and validity of delivering Lee Silverman Voice Treatment LOUD (LSVTLOUD) using synchronous and asynchronous technology. Tindall et al. (2008) reported on the use of the videophone for delivering LSVTLOUD to 24 patients with PD. They were able to demonstrate significant improvements in SPL for sustained phonation, reading, and conversational monologue pre- to post-treatment in these patients. These results were found to be comparable to previous FTF data (Ramig, Sapir, Fox, & Countryman, 2001) on all measures, except for SPL for conversational monologue. The technology used in this study is relatively unsophisticated by current standards and has obvious limitations, one being the difficulty in accurately recording SPL and vocal frequency.
A web camera and videoconferencing via Skype was used by Howell, Tripoliti, and Pring (2009) to deliver LSVTLOUD to three people with PD, in combination with FTF treatment. Participants received one treatment session per week FTF and the remaining three sessions via Skype. As accurate recordings of SPL via Skype could not be obtained, the weekly FTF session was used to record vocal SPL using a sound level meter. This study found that remote treatment resulted in gains in SPL for sustained phonation, reading, and conversational speech consistent with previous FTF treatment. Limitations of this technology included participant training, specific computer requirements, the inability to accurately record SPL during the videoconference, and the need for at least one FTF session per week.
By using a specifically designed integrated multimedia videoconferencing system, Theodoros and colleagues have overcome some of the limitations of off-the-shelf technology (Constantinescu et al., 2010a; Constantinescu et al., 2011; Theodoros et al., 2006). A randomized controlled non-inferiority treatment trial conducted by Constantinescu et al. (2011) involving 34 people with PD revealed significant improvements in acoustic and perceptual measures following treatment in both the online and FTF treatment groups. No significant differences in treatment outcomes were identified for participants across the treatment environments. This study supported the clinical validity and reliability of delivering LSVTLOUD across the Internet.
While laboratory-based studies allowed these researchers to develop and refine the technology required to deliver LSVTLOUD online, the need to provide this treatment in the home was clear. A single case study piloted the treatment with a person with PD approximately 90 kilometers away from the clinician (Constantinescu et al., 2010a). Connection to the Internet was achieved via a public telecommunications network. Following the treatment, the person with PD achieved substantial improvements in SPL in sustained phonation, reading, and conversation and in overall speech intelligibility. A larger study is ongoing to firmly establish the validity and cost-benefits of home-based delivery of LSVTLOUD to people with PD in rural and urban areas.
Ramig and colleagues (Halpern et al., 2005) have developed software (LSVTLOUD Companion) to enable people with PD to practice LSVTLOUD techniques independently. This software may be used in conjunction with FTF treatment or autonomously, following 16 sessions of treatment. The software includes calibrated measurement of SPL and frequency of voice, interactive verbal feedback on patient performance, a facility for the clinician to adjust treatment goals, and data analysis. Halpern et al. (2005) reported on the treatment of 16 people with PD who received 50% of their sessions at home using the software and the remaining sessions FTF. Results revealed positive outcomes similar to previously published data both immediately post-treatment and at a 6-month follow-up. This technology could also be used in conjunction with real-time online treatment, providing a total telepractice alternative.
A number of asynchronous computer-based interventions for aphasia have been developed (Wertz & Katz, 2004). To date, there is only preliminary evidence to support the effectiveness of many of these programs. However, advances in technology have resulted in some interesting developments in this area. Recently, Cherney et al. (2008) reported on the use of AphasiaScripts, a software program that uses a virtual therapist to provide conversational script training. When used intensively in the home for 9 weeks (30 minutes per day) and with one visit per week FTF with the clinician, the verbal output of three participants improved in content, grammatical productivity, and rate following therapy. In a further study using this software in the treatment of 20 people with aphasia, Manheim, Halper, and Cherney (2009) demonstrated both a statistical and clinically significant decrease in the Communication Difficulty subscale of the Burden of Stroke Scale (BOSS; Doyle et al., 2004) immediately post-treatment and at a 6-week follow-up.
A similar program called Sentactics has been designed to address agrammatic sentence deficits in people with aphasia (Thompson et al., 2010). The program, administered by a virtual therapist, presents a sentence-picture matching task, followed by a sentence-production priming task. Six people with aphasia who used the program were found to significantly improve their ability to comprehend and produce trained and untrained linguistically related complex sentences. There were no significant differences in results for participants who used Sentactics and those who were treated by a clinician.
Voice Disorders
Research involving the treatment of voice disorders via telepractice has emanated mainly from researchers within the U.S. military, where there is a need to provide efficient and effective services to personnel serving in diverse regions. Mashima et al. (2003) conducted a study in which 23 participants with voice disorders were treated online using a secure Internet-based videoconferencing system integrated with speech analysis software. The outcomes for these participants were compared to those for 28 other persons with voice disorders who were treated in the traditional FTF manner. Pre- and post-treatment assessments were conducted in the traditional FTF manner. Positive treatment effects were obtained in both groups with no significant differences in the measures obtained for the online and FTF environments.
Stuttering
Two studies have reported on the successful treatment of stuttering in children and adolescents (Sicotte, Lehoux, Fortier-Blanc, & Leblanc, 2003) and one adult (Kully, 2000) via videoconferencing. However, the strongest evidence to date for the validity and reliability of telepractice in stuttering comes from the Australian Stuttering Research Center in Sydney, where Onslow and colleagues (Carey et al., 2010; O'Brian, Packman, & Onslow, 2008; Wilson et al., 2004) have developed telehealth applications for the delivery of stuttering treatment to children and adults. Wilson et al. (2004) used a telephone-based application to deliver the Lidcombe program to 5 children aged 3 to 5 years. Results revealed that 2 of the children scored a mean of less than 1.0% syllables stuttered (%SS) at 12 months post-intervention, and another 2 children scored a mean of less than 2.0%SS. It was noted, however, that the telehealth delivery required more clinician time than standard delivery. The researchers suggested that, potentially, the Lidcombe program could be presented via videoconferencing, which would be more consistent with the standard FTF program.
For the treatment of stuttering in adults, Carey et al. (2010) conducted a randomized controlled non-inferiority trial of a telehealth application for the delivery of the Camperdown program. Twenty adults were treated via telephone and 20 participants were treated FTF. No statistically or clinically significant difference in %SS was recorded between the two groups immediately post-intervention, or at 6 and 12 months later. In addition, the telehealth group used significantly less clinician contact time (average of 221 min) than the FTF group.
Pediatric Speech, Language, and Literacy Disorders
While research has demonstrated positive results for the use of telepractice with adults, few studies have addressed the feasibility and validity of this mode of service delivery for addressing speech, language, and literacy disorders in pediatric populations. This dearth of studies is somewhat surprising because these communication disorders constitute a major proportion of SLP practice. Despite the limited evidence for telepractice in this area, it is acknowledged that there are SLP services being provided successfully via telepractice to children in educational facilities or through private practices.
Studies to date have reported on the feasibility and validity of the assessment and treatment of speech, language, and literacy disorders using standard videoconferencing equipment. Fairweather, Parkin, and Roza (2004) simultaneously assessed the speech and language of 13 school-aged children (6-14 years) online and FTF using standardized articulation and language tests, an informal oromotor assessment, and a language sample analysis. Results revealed levels of agreement of 69% and 92% for the overall severity of the articulation and language disorder, respectively, with complete agreement across individual subtests for 69% of the participants. Several discrepancies between the raters did occur for certain speech sounds in children with severe articulatory disorders.
More recent studies have demonstrated the validity and reliability of assessing speech, language, and literacy disorders in children using a custom-built multimedia videoconferencing system (Waite, Cahill, Theodoros, Russell, & Busuttin, 2006; Waite, Theodoros, Russell, & Cahill, 2010a, b). One study investigated the online evaluation of the speech of 20 children (4-9 years) with suspected or identified speech impairment (Waite, 2010). Measures included a speech intelligibility rating, a single-word articulation test, a phonological process analysis, an oromotor examination, phonetic transcription accuracy, and a provisional diagnosis and severity rating of the speech disorder. Overall, a high level of agreement was achieved between the FTF and online assessments of single-word articulation (91%), speech intelligibility (100%), oromotor function (91%), phonological processes (83%), phonetic transcription accuracy (84%), and diagnosis (68%) and speech severity ratings (<85%). Though the level of agreement between assessors for five speech sounds was slightly less than the clinical criteria of 70%, these were consistent with levels obtained in other FTF studies (Dodd, Hua, Crosbie, Holm, & Ozanne, 2002). Therefore, the results of this study supported the validity and reliability of assessing speech production in children online.
Waite et al. (2010a) reported on the assessment of the language abilities of 25 children (aged 5 to 9 years) online and FTF simultaneously using the Clinical Evaluation of Language Fundamentals, 4th Edition (CELF–4; Semel, Wiig, & Secord, 2003). Results revealed no significant differences between the online and FTF total raw scores and scaled scores for each subtest. Very good agreement on the individual items, total raw scores, scaled scores, core language score, and severity level were obtained between the two raters. In addition, intra- and inter-rater reliability for the online ratings was found to be very good for all measures. The investigators concluded that the core language subtests of the CELF–4 could be validly and reliably administered online. A further study using the same technology and methodology was conducted by Waite et al. (2010b) to investigate the validity and reliability of online assessment of literacy skills. Twenty children (8-13 years) were assessed on standardized literacy, spelling, and reading tests. Weighted kappa analyses on the tests' scaled scores indicated very good agreement for all parameters, while percentage levels of agreement were above 80% for most measures. Intra- and inter-rater reliability were found to be very good for all online parameters.
As far as the author is aware, there is no strong evidence to support the online treatment of pediatric speech, language, and literacy disorders. A small unpublished pilot study conducted by Waite (2010) reported on the feasibility of delivering a literacy treatment to 8 children (8-9 years) identified as demonstrating phonetic decoding or encoding deficits. This treatment was conducted in a laboratory setting between two rooms for two 1-hour sessions per week for 10 weeks. Significant improvements were demonstrated for the group for non-word spelling and reading accuracy only. Analysis of individual results revealed that each participant demonstrated gains in more than one literacy skill. Participant and parent satisfaction with this online treatment was encouraging, with the majority of children and parents responding positively to questions relating to videoconference quality, ease of use and interaction, service quality, confidence in results, and overall satisfaction.
Dysphagia and Laryngectomy
Although the delivery of SLP services via telepractice is conceivable for the communication disorders discussed above, the feasibility of managing clients with dysphagia and those following head and neck surgery seems less plausible. Recent studies, however, have challenged traditional expectations in these areas of practice.
Myers (2005) reported on the successful use of videoconferencing to provide speech rehabilitation and psychosocial support to one patient post-laryngectomy and to another following radical chemotherapy, both living in rural areas. In addition, this connection facilitated education to the family and inexperienced clinicians. In the case of a third patient, videoconferencing was used to facilitate the removal and re-insertion of a voice prosthesis with assistance of a relative and local nurse.
In two recent studies, Ward and colleagues (Ward et al., 2007; Ward et al., 2009) conducted a laboratory-based study and a remote clinical trial to validate the assessment of oromotor, swallowing, and communication outcomes of patients following laryngectomy. In the laboratory-based study (Ward et al., 2007), 20 patients were assessed online and FTF simultaneously by using a customized videoconferencing system. Results revealed greater than 80% agreement between the online and FTF assessors for all variables relating to oromotor function, swallowing status, and communication ability. Although clinicians' satisfaction with the functionality of the system was low, their ratings were high for the potential of this method of service delivery. Patients, on the other hand, were 100% satisfied with the usability of the system and the quality of service received. In a subsequent study with the technology upgraded to include a free-standing, self-focusing camera, Ward et al. (2009) investigated the feasibility of assessing patients following laryngectomy remotely over a distance of 1,700km with connection via a mobile phone network. Swallowing, stoma, and communication status of 10 patients was assessed online and FTF. Excellent levels of agreement were achieved between the two assessors. Both patient and clinician satisfaction with remote assessment was high.
The management of swallowing disorders in a patient with neurological impairments can be complex and seemingly difficult to accomplish via telepractice. The clinical evaluation of swallowing involves close observation of the patient and a greater degree of “hands-on” interaction from the clinician, compared to other areas of SLP practice. Furthermore, instrumental assessment (e.g., videofluoroscopy) of swallowing is common clinical practice and creates another level of complexity for telepractice. Inroads into the validation of an online clinical bedside assessment of swallowing have commenced through the work of Ward and colleagues. The initial study in this area (Sharma, Ward, Russell, & Theodoros, in press) involved the use of 10 simulated patients who presented with a range of dysphagia severity levels. Each “patient” was simultaneously assessed online and FTF using a clinical swallowing examination (CSE) protocol modified to suit the online environment. The CSE was administered with the support of an assistant at the patient-end. Results revealed high to excellent levels of agreement between the online and FTF assessors across all parameters of the CSE. Agreement for aspiration risk was excellent. Following this pilot study, and using a similar methodology to Sharma et al. (in press), Ward, Sharma, Burns, Theodoros, and Russell (2011) investigated the validity of online assessment of 40 patients with dysphagia from various neurological and structural etiologies. Results revealed high levels of exact agreement between the online and FTF assessors for oromotor ratings (83% to 100%), food and fluid trials (75% to 100%), and diagnosis and recommendations for future management (75% to 100%). This study provided support for the validity of online and FTF dysphagia assessment.
To date, there has been only one report of real-time videofluoroscopic examination of swallowing via the Internet. In the article, Perlman and Witthawaskul (2003) described a procedure in which a computer at the patient-end was connected to fluoroscope, from which video signals were transmitted to a controller's computer. Images were successfully captured in real-time and displayed with a 3 to 5 second delay. This application has yet to be validated in persons with swallowing disorders.
Cost-Benefit Analysis
As previously mentioned, cost-benefit analyses of SLP telepractice have been minimal. Two examples have been provided by Tindall and colleagues in their study of the treatment of people with PD via videophones. Tindall et al. (2008) compared the client-reported costs and time for 16 sessions of treatment via videophones to costs incurred for FTF treatment. The videophone treatments involved 16 hours of time, no mileage, and no other costs compared to the FTF treatments, which required 51 hours of time (travel and therapy time), $953 for mileage, and $269 for other costs. An additional analysis of the impact of videophone treatment on caregiver burden for 11 caregivers of people with PD revealed average savings of 48 hours of time, more than 92 hours of work time, and just over $1,000 per caregiver (Tindall & Huebner, 2009). The impact of telepractice services on the recipients and their caregivers should form an integral part of all future studies.
The Challenges
While the evidence to date suggests that there is considerable potential for telepractice, several challenges must be addressed before this mode of service delivery becomes integral to mainstream practice. These challenges relate to professional issues, reimbursement, clinical and cost-benefit outcome data, and available technology.
Professional issues constitute a challenge to the advancement of telepractice. In particular, clinician attitude to this mode of service delivery can present barriers to its introduction. For most speech-language pathologists (SLPs), face-to-face interaction within a clinical setting is the “gold standard” of care that cannot be substituted. The increasing evidence to support the validation of online intervention, and the potential for telepractice to enhance communicative function within a naturalistic context, will inevitably dispel this perception and lead to greater use. The training of SLPs in telepractice is an important focus for university programs and professional organizations and a means by which clinician attitudes may be altered. While guidelines for telepractice have been developed by ASHA (2005) and the Telerehabilitation Special Interest Group of the American Telemedicine Association (Brennan et al., 2010), educational programs for SLPs need to be responsive to the future needs of the profession in this respect. In the meantime, health and education providers will need to ensure that onsite training in telepractice is available to ensure the sustainability of any service via this mode.
Professional portability across states is also seen as a major challenge to the uptake of telepractice. In most countries, SLPs must be licensed to practice in the state or territory in which the client receives the services. As such, this requirement presents a logistical and financial disincentive for SLPs to engage in telepractice. Policy changes are needed on a national and state level to resolve this impasse before telepractice can become widespread.
Reimbursement for telepractice services is limited in health-care systems throughout the world, and remains one of the core hurdles to the expansion of these services. Payment for services is dependent upon the availability of strong evidence to support the effectiveness and cost-benefits of telepractice to convince insurers that these services should receive reimbursement. As yet, such evidence is not available in sufficient quantities. However, inroads into the reimbursement issue are being made in the United States, with 13 states currently providing reimbursement for allied health services. In some countries, such as the United Kingdom, Canada, and Australia, reimbursement is less of an issue due to the fact that SLP telepractice is, or will be, embedded within public health systems. However, the uptake of telepractice in SLP in any health or educational system will remain dependent upon government policy and strong evidence to support its benefits.
A further challenge lies in the technology and levels of connectivity currently available. Inevitably, a SLP will seek to replicate the FTF interaction with a client and, in doing so, will need technology that enables this process. Although there are many off-the-shelf synchronous and asynchronous technologies available, the choice of a system that is appropriately priced and able to be used across a range of clinical interactions is difficult to make at present. Ultimately, the profession requires the development of software specifically designed to meet the needs of SLPs, with the flexibility to be used on various platforms (e.g., PC-based, web-based, mobile technology). Furthermore, the installation, ongoing technical support, and connection costs associated with this technology can present a barrier for many services. While Internet access is increasing rapidly around the world, current levels of connectivity remain a significant barrier to service delivery, often in the very areas that need it. Inevitably, Internet connectivity in its various forms will improve over time, enabling ubiquitous telepractice.
Future Directions
Telepractice in SLP has an exciting future that will transform and enhance the way in which SLP services are delivered to adult and children with communication and swallowing disorders. Until that time, it is imperative that the profession accelerates its program of research and clinical endeavor in this area. In particular, the field lacks strong evidence for the cost-benefits of telepractice and for the validation of its use in a number of clinical areas. Research in the education domain is sadly lacking, despite the large proportion of SLP practice devoted to childhood communication disorders and the obvious benefits for rural and remote schools where SLPs are in short supply.
Another important research consideration is the need to develop a core set of outcome measures that may be used by researchers worldwide, which may potentially provide substantial evidence to support telepractice for insurers and government agencies. With rapid developments in technology, research should focus on the evaluation of various forms of telepractice that differ from conventional one-on-one interactions (e.g., technology enabled self-management programs), where both synchronous and asynchronous technologies may be used.
As yet, there has been minimal investigation of client characteristics that will predict a successful outcome. Currently, the decision to engage a child or adult in telepractice remains the clinical judgment of the SLP, and, in some cases, may occur on a trial and error basis. Consideration of clients' behavioral, physical, and cultural characteristics is essential in determining the suitability of an individual for management via telepractice.
The education of SLPs is pivotal to the uptake and sustainability of this mode of service delivery. For the upcoming generations of SLPs, technology in practice will not be feared, nor will it pose a hurdle. The appropriate and effective application of these tools, however, will continue to require clinical reasoning and the guidance of experienced clinicians.
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