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TeleAudiology: The Key toServing Rural Populations

EHDI Conference 2012, St Louis, Missouri

Cindy See, AuD Marshfield Clinic

Elizabeth Seeliger, AuD Wisconsin SoundBeginnings

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Background

Grant from the Federal MaternalChild Health Bureau secured by

Wisconsin Sound Beginningsin 2009

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TeleAudiology?

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Help meet EHDI 1-3-6 goals? Improve loss to follow-up

rates in the EHDI process?

Is TeleAudiology possible in a

clinical setting?

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Solution?Marshfield Clinic TeleHealth!

Dedicated TeleHealth Department withSupporting Infrastructure

Established in 1997

Based in operational clinical approaches

Not Technology oriented

Providing over 40 different specialtyservices

Experienced TeleHealth Nurse Clinicians

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Marshfield Clinic

TeleHealth

Marshfield Clinic

Centers

Skilled Nursing

Facilities

Hospitals

Indian HealthCenters

Head Start Centers

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Geography: Marshfield ClinicAudiology Locations Chippewa Falls

Eau Claire Marshfield Menomonie Merrill

Minocqua Park Falls Rice Lake Spooner Stanley Wausau Weston

Wisconsin Rapids

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Locations with

In-person

Pediatric Diagnostic ABR

Marshfield

Chippewa Falls

Eau Claire

Problem: Travel to

these 3 locationsmay exceed 2-3hours one way!

Audiology In-person Sitesprior toGrant Funding

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Locations with

In-person

Pediatric Diagnostic ABR

Marshfield

Chippewa Falls

Eau Claire

Wausau

Weston Merrill

Wisconsin Rapids

Audiology In-person SitesAfterGrant Funding

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Locations with

In-person & TeleHealth Pediatric

Diagnostic ABR

Marshfield

Chippewa Falls Eau Claire

Wausau

Weston

Merrill

Wisconsin Rapids

Minocqua

Rice Lake

Rhinelander

Park Falls

Audiology In-person andTeleHealth Sites

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Think big, start small

With Wisconsin Sound Beginnings:

Data Analysis Key locations to develop onsite and

TeleAudiology services.

Loss to follow-up rates Geographic access to services

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Audiology Equipment

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Equipment Cases

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Supplies

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Crossloop

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Crossloop Software that allows remote access

of ABR computer 128-bit encryption algorithm

Randomly generated 12-digit accesscode for each session

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TeleHealth VideoConference Systems

The patient site is a designatedclinical exam room enabled for

TeleHealth Polycom VSX7000s codec technologies

Audiologist uses the pc-based H.323video system provider

workstation Polycom PVX Software only codec with

Logitech 9000 camera and pc speakers

Includes remote control access of theexam room camera.

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Video Conference Systems

Technical Specifications

H.323 video equipment

Runs on 10-100 meg fiber network,using standards based video.

Uses IP (Internet Protocol)

512 kbps over proprietary fiber opticcable leased from two Local ExchangeCarriers.

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MC TeleHealth Approachto Care Delivery

Sessions arereal-time interactive

All calls are considered patient

consultations and are treated as suchfor HIPAA and HITECH requirements.

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Procedure

Development

Authored by TeleHealth Director andTeleHealth Nurse Project Coordinatorin consultation with Audiology

Available on the Marshfield ClinicIntranet for easy access

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Procedure Information Includes:

Pre-consult preparation of infant Equipment set-up

Skin & ear preparation

Electrode placement

Infant positioning

Post-consultation considerations

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Procedures

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Training ofTeleHealth Nurse

Clinicians Prepared In House Video Video Conference Presentation

Individual one on one consultationbefore go live date

+ From:

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Program Components

For babies who refer on the

hearing screen, the goal is toschedule two appointments priorto hospital discharge

2 weeks and 4 weeks of age

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Program Components

Audiology AppointmentRequest Fax:

Contact Info

Screening Results

Guide By Your SideCheckbox

PCP required

Insurance Info

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TeleAudiology Program

Components

Designed as a center

to center programrather than a strict

hub & spoke

concept.

Audiologist controls

the laptop andsoftware remotelyand analyzes results

in real time.

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TeleAudiologyProgram Value-Steps

Parents are provided results thesame as if they were on site.

The audiologist takes screen shots ofresults prior to disconnection ofequipment for formal report.

Results are printed and scanned intoelectronic medical record.

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Onsite Data:Sep 14, 2010 Nov 30, 2011

Four-sites - Wausau, WisconsinRapids, Merrill, Weston

Infants scheduled: 54

Passed: 39 (initial appointment)

Refused: 1

Average age: 1 month Age Range: 2 weeks 4 months

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Onsite Data:Sep 14, 2010 Nov 30, 2011

After first appointment,need follow-up: 14

5 No Shows

Need further testing: 9

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Onsite DataFinal Results (14 months, n=54)

Final number passed, includingfollow-up appointments: 46

Conductive hearing loss: 2

Refused follow-up: 1

Lost to follow-up: 3

Follow-up pending: 2

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Economic Impact:

Travel prior to grant: 66 milesaverage

New Onsite Location: 31 miles avg

Cost savings based on $3/mileformula calculation

Round trip distance saved = 70 miles $210 average dollar savings

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TeleAudiology Data:Sep 14, 2010 Nov 30, 2011 (14 months)

4 Locations: Minocqua, Rice Lake,Park Falls, Rhinelander

Infants scheduled: 34

Passed: 24 (initial appointment)

Average age: 1.1 months

Age Range: 2 weeks 6 months

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TeleAudiology Data:Sep 14, 2010 Nov 30, 2011

After first appointment, need follow-up testing: 10

4 No Shows

Need further testing: 3

*Equipment issue: 3

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TeleAudiology DataFinal Results (14 months, n=34)

Final number passed, includingfollow-up appointments: 29

Conductive hearing loss: 1

Refused follow-up: 1

Lost to follow-up: 2

Follow-up pending: 1

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Economic Impact:

Travel prior to grant: 105 milesaverage

TeleHealth Site: 25 miles average

Cost savings based on $3/mileformula calculation

Round trip distance saved= 160

miles $480 average dollar savings

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Financial Considerations

Of the 88 infants scheduled:

58 WI Medicaid (42 Onsite, 16

TeleHealth) 24 Private Insurance

(7 Onsite, 17 TeleHealth)

6 No Insurance on File (5 Onsite, 1TeleHealth)

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Case Study #1 Onsite

BB NICU Graduate Cleft Lip & Palate

Opitz G/BBB syndrome

Referred Newborn HearingScreening, bilaterally

No Show 2 & 4 week audiologyappointments in Marshfield, 33 milesfrom home

Scheduled onsite in WisconsinRapids, 3 miles from home

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Case Study #1 continued

Results Onsite, 8 weeks old:

ABR 40 dB, bilaterally Bone Conduction 20 dB, consistent

with conductive hearing loss for atleast one ear

Scheduled for coordinatedappointments with ENT, Audiology &Plastic Surgery at 11 weeks of age

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Case Study #2 TeleAudiology

BG Normal pregnancy, C-section delivery

Referred newborn hearing screen,bilaterally

History of multiple no-show & cancelledTeleAudiology appointments

Moved twice since birth Returned to original PCP

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TeleAudiology Results, 5 months old:

Passed OAE screen left ear

Referred OAE screen right ear

Initial ABR recording hard tointerpret secondary to awake state

Mom fed & snuggled baby and was

able to get baby to sleep

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ABR results

Normal ABR left ear

ABR 40 dB right ear, with

significantly delayed latencies noted,suspect conductive hearing loss

Contacted local Audiologist & PCP

Scheduled for coordinatedappointments at 6 months of age

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Quotes

TeleHealth Nurse Clinicians

Parents

We e not done et!

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Locations with

In-person & TeleHealth Pediatric

Diagnostic ABR

Mercer

Hayward Arcadia

Black River Falls ?

+ More to be consideredas project moves

forward

Were not done yet!

Future TeleHealth Sites

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So Can TeleAudiology?

Help meet EHDI 1-3-6 goals?Yes! Improve loss to follow-up rates in

the EHDI process?Yes!

Finally, is TeleAudiology possible ina clinical setting?Yes!

Documents

531 Cindy See