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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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Case Study #2 continued
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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Case Study #2 continued
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!