Integrating Telehealth into Audiology Practice: Interview with De Wet Swanepoel and Vinaya Manchaiah

Hello,

and welcome to another episode

of This Week in Hearing.

I’m Brian Taylor,

and this week we’re going to be

discussing a handy new book,

Teleaudiology Today Remote

Assessment and Management

of Hearing Loss.

And here with me to discuss some

of the important content of the

book are two of its authors,

Vinaya Manchaiah and De Wet

Swanepoel. So, De Wet and Vinay,

I want to welcome you to

This Week in Hearing.

It’s great to have you with us.

Thank you, Brian. Thanks, Brian.

It’s great to be with you.

Well,

before we talk about

the new book,

I’m guessing that most of our

viewers have seen your names,

because you’re two of the most

prolific researchers

that I know.

But I thought it would be

helpful if you could kind

of introduce yourself,

tell us about some of your work

and your current affiliations.

So, Vinay, we’ll start with you.

Hello, everybody.

I currently serve as the

professor in the Department of

Otolaryngology at the University

of Colorado School of Medicine.

I also have a clinical and

leadership position as the

director of Audiology at the

University of Colorado Hospital.

My research has several

different themes,

but I think in the last

eight to ten years,

I’ve tried to focus on

applications of digital

health and technology

using this to kind of

look at how to improve

accessibility and affordability

in ear and hearing care.

Several years ago,

De Wet and I merged our forces

in our labs to create

something called as,

the Virtual Hearing Lab.

The idea with this is to perform

studies across the globe,

particularly in the US.

And in South Africa,

in the full spectrum

of digital health,

anything from screening

to intervention.

I think in the last two years,

we

definitely have more and more

emphasis on over the counter

hearing aids,

both on the device,

but more on the service

delivery model,

trying to understand what kind

of patient population is more

suitable or have better outcomes

with over the counter hearing

aids and things like that.

Great. De Wet?

Hey Brian, Yes.

So I am an adjunct professor at

the same institution as Vinay So

University of Colorado.

So let me kind of jump

in with that.

And then I’m a professor of

audiology at the University of

Pretoria in South Africa,

where I also head up the

research for our WHO

Collaborating Center for the

Prevention of Deafness

and Hearing Loss.

It’s the only center on

the African continent,

so a lot of the.

Kind of tele-audiology linkage

is also through the work we do

with the who really trying to

make hearing healthcare more

accessible and affordable.

And we rely a lot on digital

technologies,

but also the service delivery

models that they enable,

where we can have decentralized

service delivery models,

minimally trained ones,

can facilitate a lot of the

initial services and then

remote support, tele-

audiology services to really

make sure that we provide the

necessary care to people in a

grassroots kind of level.

So a lot of work happening

in South Africa,

but also across Africa,

but then, as Vinay mentioned,

also have close links

to work in the US.

And with the over the counter

hearing aid movement.

Well,

I want to thank both of you for

being here and I want to mention

to our listeners or our viewers

that if they enter either of

your name into a PubMed search,

they will find dozens of

articles outstanding,

timely work.

So thanks for all the great work

that you do and thanks

for being with us.

And let’s just move right into

the talk about your new book and

I have a copy of it right here

for those of you that want to

know what the cover looks like.

My first question, and Vinay,

I’ll ask this to you.

I guess what motivated you

to write the book?

A few different things.

As we all know,

during the COVID-19 pandemic,

the physical distancing was put

in place and as a result,

we have to start looking at

other ways of providing care

to our patients. So,

as we all know,

the concepts of teleaudiology

are not well covered in ideology

education programs.

So a lot of the clinicians

were left

trying to find information

and hands on training

on tele-audiology.

And I think all of us had quite

a lot of requests to

present webinars,

do hands on training and

things like that.

I think that was kind of

a huge motivation.

And then I also need to give

credit to our colleague, Dr.

Bopanna Ballachanda

who kind of really put

together a team.

He basically was the one who

persuaded me and Jay to

jump on this project.

Initially we were highly excited

and kind of started

working on it,

and then other things took

priority and then we kind

of put the book on hold.

And for several reasons, Dr.

Ballachanda could not continue

on this project.

And after a gap

a little bit of a gap

De Wet and Eldre

joined the team.

And we also had a few

external colleagues. Samantha,

Laura and Sophie Brice

contributed some excel chapters.

So with these things

we managed to.

Get the book on book out

in the last few weeks.

Maybe.

One thing to add was also before

we start working on the project,

we kind of looked at what

is out in the market.

So there is a textbook

on tele audiology

with good information but

a little bit dated.

But also it did not have the

practical information on it.

It was more theoretical,

covering the concepts

of teleaudiology.

So we wanted to provide more

hands on consulting style

information in this text.

That’s good to know

and I’d be remiss.

Not to mention you have two co

authors that couldn’t join us

today, Eldre Beukes and Jay Hall.

And I just want to

acknowledge that

we have four co authors

of the book.

We’re glad that two of you could

be with us. So, Vinay,

tell us a little bit more about

how the book is structured or

organized chapter by chapter.

Yeah,

so we have kept the book fairly

short so that it is

not a heavy read.

And the book is targeted at

practicing clinicians and also

students who doesn’t have any

background or information

in teleaudiology.

So we assume no previous

knowledge or background.

And the book has eight chapters.

We start with an opening chapter

on covering general concepts,

definitions and models,

things like that.

And following that we kind of

jump right into setting

up the clinic,

what kind of equipment you need,

how to set up your clinic for

different types of teleaudiology

practices.

Following that,

in the third chapter we have a

little bit of information

on ethical,

legal and professional issues

that clinicians need to be aware

with the teleaudiology practice

in mind. And following that,

we have four chapters covering

screening and diagnostics

informational,

counseling and shared

decision making,

fitting hearing aids and

fine tuning them.

And then finally tele

Rehabilitation,

providing Rehabilitative

services through Teleaudiology

practices.

And finally we also have a brief

chapter covering challenges

and opportunities,

more futuristic ideas and things

like that. So, yeah,

fairly short text but keeping

the practical content in

most of the chapters.

Also want to mention that all of

the authors in these books

are clinician scientists.

They are well known researchers

in the field,

but also clinicians who have had

excellent experience with

patients. Right, that helps.

Exactly.

And you mentioned the

book is practical,

so maybe you give us

some examples.

We can start maybe with one of

the earlier chapters around

screening and diagnostics and

provide us some example.

Of how teleaudiology might be

used in that area of care.

Brian yes happy to kind of share

some ideas there maybe just to

reiterate one or two things

that Vinay also mentioned.

This field is such a rapidly

evolving and changing field.

I think back

13 years ago,

we did a systematic review

with Jay Hall,

who’s one of the co authors on

the book as well on teleaudiology

and all the publications that

were available at that stage,

and it was just 27 publications,

so early days.

And if you look at the number

of papers out now,

it’s exponential growth that

we’ve seen into a variety

of different fields.

It’s not just telehealth,

it’s also mHealth,

there’s eHealth and there’s

digital health and the models

even five six years ago were

very simple to explain.

We had synchronous and

asynchronous models,

but now it’s a little bit more

diffused and difficult to always

kind of structure into clean

little boxes because we have

things like online services

and we have chatGPT.

All these things are kind of

weighing into the way in

which we deliver care.

But in terms of maybe some

practical examples,

as you mentioned,

the chapter four really covers

the screening and the diagnostic

components in tele audiology.

And as Vinay mentioned,

we’ve tried to take a really

practical approach so that

clinicians can really work

through the content and also

implement these solutions

so in this chapter,

we give a couple of examples.

I mean,

maybe one of the traditional

examples is something like

electrophysiological assessment

of newborns who failed their

hearing screening in remote

locations of Canada, Alaska,

for example,

if a child fails,

there’s no one there to do the

ABR or the auditory steady

state response.

So telehealth is perfectly

positioned for remote assessment

where a child can be hooked

up by a technician to the

electrodes and the equipment.

And we can take remote control

of the equipment,

a specialist audiologist,

and they can run through that

electrophysiological assessment

to determine if the child has

a hearing loss and if they do,

what the degree and

configuration of that loss is.

So that’s a typical kind of

synchronous telehealth example

we’ve also given some examples

of some of the newer

technologies, for example,

online hearing

assessments or screenings that

can be conducted that clinicians

can include in their websites

where a test can be conducted

and they can then remotely

well it’s asynchronous,

so it can run 24/7.

So they can actually serve

patients while they’re in bed,

but the next day they can look

at the list of patients that

have been referred and

then contact them.

So that’s just a simple example

of an asynchronous way.

In which a telehealth mode

can support practices and

audiological care.

Very nice.

Could you tell us some examples

in other chapters around

fitting, hearing aids,

auditory training or

rehabilitation,

any type of follow up,

maybe provide some examples of

how teleaudiology is being

used in those areas? Yes.

So we have an excellent chapter,

Sophie Brice,

who has been doing teleaudiology

for quite some time,

I think at least over a decade.

She has an outstanding chapter,

particularly on hearing aids,

how to fit hearing aids as well

as how to fine tune them and

what kind of things that are

possible through that model.

And as we know that

soon after the pandemic,

most of the manufacturers kind

of quickly made that feature

available for most of the

hearing aids and provided

training on how to fit and fine

tune hearing aids through

teleaudiology models.

And in addition,

I think the other thing that

is happening in that space,

particularly with CI,

is using smartphone applications

for close monitoring

of patients. Now,

at least one manufacturer has

this app already and then others

are coming onto the board very

quickly where you can perform

some testing, for example,

digits in noise testing and try

and understand what is the

status of the patient and also

get some of the questionnaires

and things like that completed

so that you have a much closer

monitoring of patients.

Traditionally you would have

them visit every few months

and when they’re stable,

maybe every year or so,

whereas with this technology you

could actually monitor them very

closely and potentially reduce

the need for some appointments

or create a need or bring them

in when there is a need that

shows up in this closed

monitoring. In terms of rehab,

that’s a whole another thing

that we have not really

done very much.

So I think whenever we think

about tele audiology,

we often think about screening

and diagnosis and maybe a little

bit about fitting hearing aids

and things like that.

So what we see when we often

talk to patients is especially

those who are far away,

is they actually don’t mind

coming to that initial

appointment to come get the

screening done and diagnosis

completed and maybe even have

the hearing aids fitted.

But it’s actually the rehab side

that may benefit hugely from

teleaudiology models. One,

because it may require several

repeated appointments

and the second,

we are also not able to charge a

lot of the insurance does not

cover for rehab services.

So there are, I think,

some very useful and interesting

things that can be provided.

It both as a replacement care

for rehab as well as

supplementary care.

You could have a couple of in

person appointments and then

time in between can be

well used providing self led

educational services

through web based but now more

as an app based applications for

all kinds of populations. Oh,

that makes sense.

And that kind of leads my next

question is how do you see

teleaudiology working

with in person care?

I think some people refer to

that as blended or hybrid care.

Can you give us some examples

maybe of how teleaudiology would

work in tandem with in person

visits? Yes Brian,

I mean I think that’s the most

typical way that telehealth

models are rolled out in clinics

is where it kind of supplements

in person services in a way

where some components are

offered as a remote option.

It’s usually hybrid.

There’s very few models that are

fully telehealth from

start to finish.

So I think many of the examples

we mentioned for example,

support for hearing aid fitting

or fine tuning,

having the option to connect

with an audiologist and have

them make remote adjustments and

changes and fine tune the

hearing aid remotely.

But they’ve come in initially

as an in person appointment,

initially to connect with

audiologist and to do

the initial fit.

That’s quite typical.

I also think there’s hybrid

models now that also kind of

blend in with the screening

component.

I mentioned the initial kind of

online use of a screening

component where they connect to

a practice without actually

connecting with an audiologist

but they’re doing a screening

test or they’re leaving a

questionnaire that’s completed.

All of those are elements

of a hybrid model.

If they then move into a face to

face appointment thereafter.

I think patients are

increasingly having these as

potential options that

they can pursue.

And we have definitely seen a

shift with COVID Before COVID

telehealth was really very

much a kind of ad hoc,

small little service for some

patients who felt that this was

a convenience for them.

But for audiologists it was

typically an inconvenience.

And COVID certainly has changed

the landscape tremendously.

Suddenly everyone is used to

having a remote meeting like

we’re having today so it’s not

something that’s strange

anymore.

There was initially a lot of

concern and pushback in

telehealth and teleaudiology

as well around.

Is the engagement that you have

through these means going to be

equivalent to the engagement

you’re going to have in person?

I think COVID has kind of

sorted out a lot of.

The concerns around that.

You can still build

good rapport.

You can actually have a really

quality interaction

and conversation,

very much like we’re

also enjoying now.

And it has opened up people’s,

they’re just more open to try.

There’s been a couple of surveys

out in the UK and the US as well

where health engagements through

remote, it means,

has become the preference for

many groups of patients.

It’s just convenient and it

offers them a way to connect

with the health providers

without having to travel and

take out the time of

their schedule.

I think there’s been a lot of

changes that have really enabled

telehealth over the

last three years.

That’s all good to know.

And I guess my next question is,

and maybe it’s not in the book,

but I’m sure that you might have

some thoughts on this and it’s

what type of patient, be it age,

be it

type of problem that brings

them into the clinic.

What are some insights that you

might be able to share with our

audience around who

might prefer tele,

audiology at least as

part of their care?

Maybe I can share one or two

thoughts and then see.

Renee wants to kind of fill in.

Brian,

I think the one thing we have

seen is that patients who like

to self manage their health,

to be in control of

their health,

typically tend to like the idea

of telehealth because it gives

them the convenience,

but also a little bit of the

control in how they engage with

healthcare providers

in that respect.

It also kind of links with

people who typically are a

little bit more tech savvy,

who are comfortable

with technologies,

who typically just are more open

to try a telehealth model and

then that links a little

bit to age, of course.

So if the tech savvy

component comes in,

it’s usually also individuals

who are younger. But again,

these are just generalized

observations.

I think there’s been a little

bit of work on this.

We certainly need more research

to kind of see which patient

groups and maybe even kind of

personality types fit a

telehealth model and just not

telehealth in general,

but what types of telehealth

models and access points.

So those are just some of the

initial thoughts from my side.

Yeah,

I have a few things to

add as well, Brian.

I think there’s certainly

a gap in this area.

I think we fully don’t

understand who are a right

candidate for teleaudiology.

I fully agree that

highly motivated,

a person with ability to self

manage would be a good candidate

with some technological

competency.

Those are like two requirements.

But I’ll give you a couple of

examples why I think we don’t.

Fully understand. For instance,

now almost all the hearing aid

manufacturers have a smartphone

applications and as you know,

audiologists kind of tend to

decide who is the right

candidate for using an app and

we either over or underestimate

who is the right candidate

for using an app.

So I don’t think there is a good

way for us to say who would

actually be better served

onboarding this an app.

And another example that I’ll

give you is from one

of our studies.

We have done a series of studies

looking at the efficacy and

effectiveness of internet based

CBT for tinnitus that our

assumption was that obviously

middle or anger age population

would be well suited to this

because they use the internet

quite a lot and older age

individuals may struggle.

In addition to looking

at the outcomes,

we also did something called

as a process evaluation,

which is very popular in the

business world, looking at well,

we got from A to B,

we got the outcomes,

but what are the drivers that

facilitated through

this process?

As a result of that process

evaluation,

we kind of gathered quite a lot

of data that we wouldn’t gather

in a traditional clinical trial.

For instance,

we kind of looked at

how many people actually

came into this website,

how many hits we got,

and then how many of them

actually did the screening and

how many signed up to the study

and how many of them actually

ended up staying in the study

and completing the study. Right.

We looked at their demographic,

like including age and

to our surprise,

we had a very heavy aged and

middle aged population who would

come into the website

and sign up.

But when we looked

at who actually

went on to complete the study,

it was mainly older adults with

Tinnitus. So to our surprise,

I think we probably have

to look at this

with an open mind who

may be eligible,

are interested and who do well

with teleaudiology models.

Yeah,

that’s really interesting

because in my own experience,

somebody that you think is not

very tech savvy turns out to

be incredibly tech savvy.

So you don’t always know based

on their age. Yeah,

that’s good to know.

Final question for De Wet,

I’ll address this to you.

Where can people find the book?

Yeah,

that’s a very good question,

Brian.

So the book is available

on Amazon,

so there’s a print version,

but there’s also a Kindle

version and of course that’s

available anywhere in the world.

Maybe.

It’s also just important to note

that all the proceeds from this

book is being donated for

research into making ear and

hearing healthcare more

accessible in Southern Africa.

So the idea here is that

we wanted to make.

Is available as a resource.

But we also wanted to make sure

that the proceeds from the book

keeps kind of feeding

accessibility in terms of hearing

health care in underserved

regions.

So that’s just an important note

that we like to kind of bring

under the attention of

potential readers.

That’s great.

And any final, Vinay so I have

one thing to add to that point.

The reason we chose Amazon

Direct Publishing is the ability

to quickly get the information.

As we know,

this is the field where things

are evolving very quickly.

The information that we provide

here may not be current or up to

date in a year’s time or maybe

even a few months time.

If you had gone with a

traditional publisher,

then there is certain checks and

balances that kind of delays the

process of updating the book.

It would take at least a six

months or a year process.

So the reason we went with

Amazon Direct Publishing is if

you do find any of these

concepts are outdated,

we can quickly update the book

with this information in a

matter of days or weeks.

So we welcome any feedback the

users may have and suggestions

for improvement for the future

versions so that we can update

and keep the information

current. That’s great.

And we’ll put a link on the

bottom of the screen so people

know where they can find

the book online.

So thank you for that.

And thanks to both of you.

Vinaya Manchaiah,

De Wet Swanepoel,

two of the co authors of

Tele Audiology Today,

remote
Assessment and Management

of Hearing Loss,

thank you so much for taking

time out of your busy schedules

to be with us today.