Clinical Governance and Teleaudiology

by Sophie Brice, PhD

The field of audiology has experienced significant changes in recent years with the preparation for Over-The-Counter legislation in the USA for provision of hearing aids without a clinic or Audiologist. Closer to home we are experiencing government investigations into Audiology practices in Australia and a growth of Teleaudiology compatible products now coming from all manufacturers.

“Self-fit” is a term describing hearing aid products and services in which a client can fit and program their hearing device entirely independently. This has been in existence in Australia for the past decade.

The self-fit approach is therefore compatible with the premise of Direct-To-Consumer (DTC) hearing aid provision in which a hearing aid can be purchased without support from an Audiologist, which in turn has paved the way for the idea of Over-The-Counter hearing aid provision.

 

Teleaudiology and Direct to Consumer (DTC) Hearing Aids

 

For the last 6 years, I have been part of a Teleaudiology team working with self-fit products delivered in an omni-channel, or sometimes called blended service model, in which clinic-based and Direct-To-Consumer hearing aid provision has been offered for the past decade.

In this model, clients can interchange between clinic and online services for purchase, fitting, and support with their hearing aids. This has given me a unique insight into the learnings and reflections for clinical practice and client outcomes as applies to self-fit and DTC practices.

There are so many parts to the moving machine that is the modernisation of Audiology practices to allow Teleaudiology, DTC and self-fit to work effectively and in this article I hope to simply start a conversation where we can begin to address some of the questions and implications of Teleaudiology and how this actually fits with Clinical governance.

To start, it is worth revisiting what Teleaudiology means. A quick internet search for the definition of Teleaudiology yields is a couple of common definitions; one of which is from much earlier in the decade that describes the use of electronic technology and communications to support clinical activities (Northern, 2012).

This definition does not address implementation of clinical services, or whether self-fit, DTC, diagnostic or rehabilitation are compatible or not.

An interesting contrast however is found elsewhere such as the Wikipedia (2018) listing which specifies the “use of Telemedicine to provide audiological services and may include the full scope of audiological practice”. So one big issue is that we aren’t always clear what we each mean by the term Teleaudiology.

For several decades now, the Veterans Affairs in America has used telecommunications between 2 sites, one with the client and the other with the Audiologist communicating with assistance of a health professional or assistant present at each site.

This approach fits more closely with Northern’s definition of Teleaudiology, and indeed has also been adopted successfully in more recent years by Triton in New Zealand. This version of Teleaudiology however is still a clinician-driven service model.

Modern advancements have allowed Teleaudiology services to go beyond supporting clinical practices, to being able to conduct clinical tasks such as hearing assessment, and fitting of a hearing aid led by a client (Blamey, Blamey and Saunders 2015) such that the client can accomplish these tasks entirely independently or guided by a clinician via in-app support or other communication between the two parties. This, client driven version, is that which is practiced at Blamey Saunders hears based in Australia (Saunders 2019).

Teleaudiology models have recently grown with new companies such as Listen Lively in America and a new consultation service only model by Hearing Collective in Australia where the Audiologist offers various online consultation services irrespective of the device a client may have.

Similarly, there has been a growth of Teleaudiology compatible products, programming tools for clients and clinicians, and client-centered hearing assessment methods, coming from all the major manufacturers of hearing devices; all available for Audiology professionals to work with or adopt as much or as little Teleaudiology a person is comfortable with.

 

Teleaudiology and Client Outcomes

 

Whether we are working in a traditional clinic model, blended model or providing aftercare for a self-fitted client, clinical governance is an important component of our profession to keep us as professionals accountable to our professional standards and duty of care.

A very good question raised on the VA website of Teleaudiology is ”How will professional standards be maintained?” (Audiology, 2019).

This important question is an opportunity to understand that clinical governance need not conflict with wanting to keep up with changes in consumer or product trends.

Clinical governance for traditional clinic based and Teleaudiology practices, as found at Blamey Saunders hears, assures the highest standards of clinical and Teleaudiological care based on high quality models of care (Saunders, Brice and Alimoradian, 2019) and Australia’s Commission on Safety and Quality in Health Care (2017).

Indeed other medical fields also observing a growth of Digital Health and service models, have started to respond with conversations around standards, certifying and measuring performance of online health services, such as for mental health programs  in Australia (ACQSHA, 2019).

The definition of clinical governance according to the Australian Digital Health Agency is “A system through which organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care” (ADHA2017). Teleaudiology is no exception.

Given the variation in our understanding of what Teleaudiology is, this raises the importance of clarity on what Teleaudiology practices should be? What should the standards be? As well as asking how do they apply in the age of self-fit and DTC?

 

Self Fit and Blended Models of Care

 

To help address these questions, it is helpful to look at what has already been in practice, what has been learnt and what the observed outcomes with self-fit in a blended model have been.

The current conversations around DTC and self-fit like to talk about ‘Empowerment’, with clinical conversations occurring around ‘Person-Centred Care’ (Williams, Cowan and Barr, 2019). These contemporary ideas however are hardly new as they have been with us since the very beginning of the 80s.

I will list some of the great ideas and initiatives relevant to the contemporary hearing care profession:

1. 1981 – Goldstein and Stephens propose their model of ‘Enablement’ where the client is being enabled to achieve their individually relevant outcomes (Goldstein & Stephens, 1981). 
2. 1991 – Clark et al focus on self management where psychosocial coping should be given more space in clinical management of chronic conditions (Clark, 1991).
3. 1992 – Schwarzer publishes a book on ‘Self-Efficacy’ as applied to health, in this book Bandura has become commonly referenced along with his earlier Social-Cognitive Theory developed for learning/education psychology (Schwarzer etal, 1992).
4. 1996 – Wagner et al outline elements of the Chronic Care Model, published again in 2001 (Austin, Wagner, Hindmarsh, & Davis, 2000; Wagner, 1996).
5. 2004-8 –Stuart Gatehouse and Bill Noble address Auditory reality, and ecology highlighting the individuals environment and capabilities in shaping their needs and experience of hearing (Gatehouse & Noble, 2004; Noble, 2008).

Goldstein & Stephens model of enablement, upon which the Blamey Saunders hears service model is greatly shaped by, or Wagner’s Chronic Care Model do not dictate where the care is actually occurring. This is a crucial component as those who have been practicing Teleaudiology, across the world I’m sure, will easily agree that the most important skills needed are not restricted by the chosen device/tool being used.

When the choice, fitting, adjustment and commitment to hearing health is shared with the client, the clinicians expertise and guidance become even more important to achieve a successful outcome. The reduction of access barriers to uptake of hearing support equally mean reduction of barriers to giving up or sending back hearing aids for refund.

So, more than anything, a self-fit/DTC product forces the provider to have a very high standard of supporting and delivering Enablement, self-management, self-efficacy, Person-centred care and the Auditory Reality of a person ecology.

 

Improvements in Self-Efficacy and Satisfaction?

 

In 2018, Blamey Saunders hears reviewed third party reviews by clients for product and service, finding that those who chose to acquire their self-fit device online (DTC) were consistently giving higher ratings than traditional clinic based clients, i.e., those who chose DTC were happier with their choices (Brice and Saunders, 2019).

This strongly highlights that there is no need to compromise on clinical governance just because you let go of needing to be in the same room as your clients. If a client is unhappy with their product or service, the priority on addressing their needs is still there, you simply get more creative in how you can help.

Personally, I have been part of a Teleaudiology team for over 6 years now supporting self-fit products in a DTC delivery, and there is no distinction between the challenges that clients will struggle with in the clinic vs in their home.

There are advantages for the clinician as well as the client operating online or in person, such as deeper emotional engagement found when clients interact online (contradictory to popular assumption!) (Yellowlees and Shore, 2018).

On the flipside there are difficulties in handling or inserting hearing aids that may be easier to address in person, and many more factors and observations worth discussing in more depth another day.

 

Addressing Concerns

 

A common concern that gets raised about Teleaudiology practices is around the capacity to identify any potential pathologies. Breaking up the client journey into its parts should help clarify what is important and what is the responsibility at each step. The notion of provision of hearing aids commonly gets blurred with the notion of selling a hearing aid for profit.

In conversations around Teleaudiology, I often hear the function of fitting a hearing aid getting unfairly blurred with the purpose of diagnosing a hearing loss. The responsibility of identifying pathology lies in the use of diagnostic tools and interpreting the data.

An important responsibility of any health care professional supporting a hearing impaired person is to provide appropriate advice and education about the condition that a client and their hearing loss present us with. In my opinion, informed decisions and education for the client about their hearing loss is a responsibility for any hearing care provider supporting a client’s hearing aid journey.

Clarity on what we are trying to achieve when providing and supporting hearing aids, whether our services are online or clinic based, is something I at least hope to see more of in conversations around Teleaudiology practices.

Advancements and development of new tools for clinical practice/tasks is an exciting area that is now growing, possibly as a result of the variation in service models occurring to accommodate DTC. One tool that is used in DTC hearing aid provision is the Consumer Ear Disease Risk Assessment (CEDRA) developed by the Mayo clinic and Northwestern (Klyn et al 2019).

This tool was indeed developed with the responsibilities and practical use in DTC in mind to enable consumers with potential complexities to be identified and consequently be informed or encouraged to seek important guidance from a medical professional.

Consumer safety is how this responsibility is referred to and very much reflects the priorities of clinical governance. Any hearing care provider part of a DTC model in turn has an important task to assure a tool like CEDRA is used properly, and that the client is informed of the advice they should receive for their own hearing loss and needs. From my own professional experience, clients who pro-actively seek DTC options often have a clear motivation. It may be that they do not want to see or speak to clinician due to a lack of trust or prior negative experience.

As a Teleaudiologist I carefully assure each client receives the information they need to hear, whether I can make them follow through with it or not. In this exact same way in a traditional clinic some clients may clearly receive benefit from their hearing aids yet sometimes return the devices for refund, walking away from the hearing care they clearly need.

We as hearing care providers cannot make a client do what’s best for them. The best we can do is assure they have access to information, tools and support to enable them to make and commit to the best choices for themselves.

 

Changing Landscape of Audiology and Hearing Care

 

The modern landscape of our field of Audiology has seen some exciting growth and opportunities lately.

While there are many concerns as well as curiosity around new methods, now is an important time to consider clarifying what Teleaudiology means to us. It is also now vital to be open to what Teleaudiology can enable us and our clients to do, how this impacts our clinical practice, and most importantly; how we should revise our clinical governance to assure our standards of care and service remain as high as they are, no matter how we choose to continue supporting hearing care for our clients.

 

 

References

1. ADHA: Australian Digital Health Agency. (2017). Clinical Governance Framework v2.0. Australian Government
2. Australian Commission on Safety and Quality in Health Care. (2017) National Model Clinical Governance Framework. Sydney: ACSQHC; 2017.
3. American Academy of Audiology (2019). Current Practices in Teleaudiology. Practice Management. Retrieved from https://www.audiology.org/practice_management/resources/current-practices-tele-audiology
4. Austin, B., Wagner, E., Hindmarsh, M., & Davis, C. (2000). Elements of Effective Chronic Care: A Model for Optimizing Outcomes for the Chronically Ill. Epilepsy Behav, 1(4), S15-S20. doi:10.1006/ebeh.2000.0105
5. Blamey, P., Blamey, J., and Saunders, E.. (2015). Effectiveness of a teleaudiology approach to hearing aid fitting. Journal of Telemedicine and Telecare. Vol 2: 8; 474-478.
6. Brice, S., and Saunders, E. (2019, 21-23 October 2019). A blended model of care in hearing health. Paper presented at the 19th Successes and Failures in Telehealth Conference (SFT-19) and the 11th Annual Meeting of the Australasian Telehealth Society, Surfers Paradise Marriott, Gold Coast, Queensland.
7. Care, A. A. C. o. S. a. Q. i. H. (2019). Certifying Digital Mental Health Services: Discussion paper for consultation participants. Retrieved from Lvl 5, 255 Elizabeth Street, Sydney, NSW 2000:
8. Clark, N., Becker, M., Janz, N., Lorig, K., Rakowski, W., and Anderson, L.. (1991). Self-management of Chronic Disease by Older Adults. Journal of Aging and Health, 3(1), 3-27.
9. Gatehouse, S., & Noble, W. (2004). The Speech, Spatial and Qualities of Hearing Scale (SSQ). Int J Audiol, 43(2), 85-99. doi:10.1080/14992020400050014
10. Goldstein, D. P., & Stephens, S. D. (1981). Audiological rehabilitation: management Model I. Audiology, 20(5), 432-452. doi:10.3109/00206098109072713
11. Klyn, N. A. M., Kleindienst Robler, S., Bogle, J., Alfakir, R., Nielsen, D. W., Griffith, J. W., … Zapala, D. A. (2019). CEDRA: A Tool to Help Consumers Assess Risk for Ear Disease. Ear and Hearing, Publish Ahead of Print. https://doi.org/10.1097/AUD.0000000000000731
12. Noble, W. (2008). Auditory Reality and Self-Assessment of Hearing. Trends in Amplification, 12(2), 113-120. doi:10.1177/1084713808316172
13. Northern JL. Extending hearing healthcare: Tele-audiology. Hearing Review. 2012;19(10):12-16
14. Saunders, E. (2019). Tele-Audiology and the Optimization of Hearing Healthcare Delivery (pp. 1-274). Hershey, PA: IGI Global. doi:10.4018/978-1-5225-8191-8
15. Saunders, E., Brice, S., & Alimoradian, R. (2019). Goldstein and Stephens Revisited and Extended to a Telehealth Model of Hearing Aid Optimization. In E. Saunders (Ed.), Tele-Audiology and the Optimization of Hearing Healthcare Delivery (pp. 33-62). Hershey, PA: IGI Global. doi:10.4018/978-1-5225-8191-8.ch003
16. Schwarzer, R. (1992). Self-Efficacy: Thought control of action (R. Schwarzer Ed.). Abingdon, Oxon, OX14 4RN, U.K.: Routledge.
17. Wagner, E., Austin, B., and Von Korff, M.. (1996). Organizing care for patients with chronic illness. The Milibank Quarterly, 74(4), 511-544.
18. Wikipedia contributors. (2018, December 3). Tele-audiology. In Wikipedia, The Free Encyclopedia. Retrieved 03:18, December 5, 2019, from https://en.wikipedia.org/w/index.php?title=Tele-audiology&oldid=871820436
19. Williams, G., Barr, C., and Cowan, R.. (2019). Are you providing Person-Centred hearing care? The Hearing Journal, 72(2), 18, 20, 21. doi:10.1097/01.HJ.0000553579.84972.47
20. Yellowlees, P., and Shore, J.. (2018). Telepsychiatry and Health Technologies: A guide for mental health professionals (1 ed.): Amer Psychiatric Pub Inc.

 

About the Author

Sophie Brice is the Course Coordinator of the Teleaudiology program and researcher in Digital Health at Swinburne University of Technology, alongside developing and delivering Teleaudiology services at Blamey Saunders hears. She is a researcher and author in the field of Teleaudiology, now launching the world’s first dedicated global course for hearing care professionals to upskill in Teleaudiology in 2020.