Annals of Otology, Rhinology & Laryngology I20(7):44l-447.

2011 Annals Publishing Company. All rights reserved.

Audiology Telepractice in a Clinical Environment:

A Communication Perspective
Ellen S. Crowell; Gregg D. Givens, PhD; Gloria L. Jones;
P. Bradley Brechtelsbauer, MD; Jianchu Yao, PhD

Access to adequate hearing health care is an obstacle that many individuals face worldwide. The prospect of providing
audiology services via the Internet is an attractive and viable alternative to traditional face-to-face interaction between
patients and audiologists, thus affording improved access to hearing health care for traditionally underserved popula-
tions. This article details our experience of using a web-based system with wireless audiometers and videoconferencing
software to administer remote audiological assessments in an active medical practice. It discusses the technological infra-
structure used and the pragmatic issues that arise when the Internet, Bluetooth wireless audiometers, and videoconferenc-
ing devices are converged into a clinical setting. Patients at a local office of otolaryngologists were recruited to participate
in a study in which remote assessment results were compared to those collected from a traditional face-to-face assess-
ment. Preliminary data demonstrated that the assessment results from the two sources were comparable. We conclude
that remote hearing assessment over the Internet can be achieved through a distributed system synthesized with Internet,
wireless communication, and videoconferencing technologies, supported by appropriate staff.
Key Words: audiology, otolaryngology, telemedicine.

INTRODUCTION the opportunity that telepractice can provide to these

Telemedicine is a form of health care that has individuals could open doors to the hearing world,
been in existence for decades,' yielding published as well as ensure that "the quality of services deliv-
results in areas including, but not limited to, der- ered via telepractice [are] consistent with the quality
matology ,2 radiology,3 4 and psychiatry.^-^ More re- of services delivered face-to-face.""<P') Some areas
of research focusing on providing audiology ser-
cently, telepractice has been applied to the diagnosis
vices via telepractice include video-otoscopy,'2 au-
and treatment of communication disorders.^"^ The
ditory thresholds,'-^''' hearing screenings,'-^ immit-
inability to effectively communicate with one's sur-
tance measurements,'^ distortion product otoacous-
roundings is a struggle that some individuals face on
tic emissions (DPOAEs),'^-'^ auditory brain stem
a daily basis simply because they have limited or no response testing'9'20 (also Campbell and Hyde, un-
access to hearing health professionals. In audiology, published observations), cochlear implant program-
as in many other health professions, there is a gap ming,'-2' and the administration of the Hearing in
between those needing services and those providing Noise Test (HINT) .22
services. According to the World Health Organiza-
tion, it was "estimated that in the year 2005 there East Carolina University (ECU) has been devel-
were 278 million people in the world with disabling oping and conducting research on telepractice in the
hearing impairment""'(P") and "a further 364 mil- audiology field for many years and has continually
lion people [were] estimated to have a mild hearing worked to develop better and more accessible sys-
loss."'0<P"' These staggering numbers provide a cat- tems. In 2003, Givens and Elangovan'-^ introduced a
alyst for the need to develop infrastructure and plans system that was able to administer pure tone air and
to effectively assist these individuals with hearing bone conduction audiometry by remotely manipu-
needs even when hearing health professionals can- lating a standard audiometer via the Internet. Elan-
not provide services face-to-face. As stated by the govan'"' described a similar study, also performed at
American Speech-Language-Hearing Association, East Carolina University, that tested the feasibility
From the Department of Communication Sciences and Disorders. College of Allied Health Sciences (Crowell, Givens), East Carolina
University Telemedieine Center, Brody School of Medieine at East Carolina University (Jones), and the Department of Engineering,
College of Technology and Computer Science (Yao), East Carolina University, and Eastern Carolina ENT Head and Neck Surgery
(Brechtelsbauer), Greenville, North Carolina. Drs Givens and Yao, along with East Carolina University, have a provisional patent re-
garding the web-hased system described herein.
Correspondence: Gregg D. Givens, PhD, Dept of Communication Sciences and Disorders, College of Allied Health Sciences, East
Carolina University, Greenville, NC 27834.

441
442 Crowell et al, Audiology Telepractice in Clinical Environment
Internet;
Web browsing/- ^ TCP/IP
Telemedicine suite
(Audiologist)
of assessing DPOAEs by remotely manipulating a
computer that housed the required testing software.
Reportedly, these researchers collected comparative
data for both the pure tone audiometry results and
the DPOAE results on site and from a distant loca-
tion.
More recently, a web-service based system that
could potentially support a subscription model was
developed at ECU through a partnership between
the Department of Communication Sciences and
Disorders and the Department of Engineering .^^
This web-based system was developed to serve as
the medium to conduct audiological assessments via
telepractice applications specifically through the use
of the Internet.
AUDIOLOGY TELEPRACTICE IN CLINICAL
ENVIRONMENT
At present, an effort is ongoing to identify pos-
sible networking and operational issues in imple-
menting the web-based service system in a clinical
setting, as well as documenting the feasibility and
reliability of such a system.
The discussion below relates to this ongoing effort
relative to technological infrastructure and pragmat-
Otolciryngology office (Patient)
Telemedicine center (Audiologist)
Science Technology Building (Web server)
I 500m I
Fig 2. Local map (Greenville, North Carolina, retrieved on October 21, 2009, from website maps.google.com) of testing sites
and web server.
Internet;
Otolaryngology Fig 1. Data exchange between audiolo-
gist and patient through web server.
office (Patient)
ic issues that were encountered with the networking
system, as well as preliminary results.
Description of Web-Based Audiology Teleprac-
tice System. A detailed description of the web-based
system can be found in previous publications.^-^-^"* In
brief, the central part of the remote hearing assess-
ment system is a web server, which hosts all appli-
cation-level programs, as well as the required data-
base (Fig 1). The web server was implemented with
a three-tier architecture to improve software mod-
ularity and portability.2^^ Audiologists, who will be
operating the testing application, log in to the serv-
er with web browsers through their terminal com-
puter to operate a remote audiometer. Currently, the
web server is set up as a virtual machine located in
the Science and Technology Building at ECU. The
server runs a virtual data-center operating system
ESX with 3.5 updates from VMware Inc. The vir-
tual machine features dual 3.4 GHz central process-
ing units and 2 GB RAM and is set up as a Windows
2003 Pro Virtual Server. For our system, the data-
base is implemented on the same virtual machine as
the web server. For protection of the security of data
exchanged between the audiologist terminal and the
server, the server can only be accessed with SHTTP,
the Secure Hypertext Transfer Protocol; thus, neces-
Traffic II More ] | Map ( Satellite | Terrain |
 Crowell et al. Audiology Telepractice in Clinical Environment 443

Fig 3. Remote audiologist, located at

East Carolina University Telemedicine
Center, has views of web-based system
(far left), patient (center), and view seen
by facilitator at otolaryngology office
(far right).

sary data encryption is provided. a wireless Bluetooth-Ethernet gateway device. In

both cases, the on-site facilitator is only required to
Testing Sites and Equipment Utilized. In our cur- power on the audiometer in order to provide remote
rent study, two sites were used to assess the web- access by the audiologist.
based system. The ECU Brody School of Medicine's
Telemedicine Center served as the remote site, and The videoconferencing system setup for this loca-
a local otolaryngology office was the designated on- tion was slightly different from that of a normal tele-
site location (Fig 2). By incorporating the traditional medicine encounter (Fig 4). A VSX 3000 desktop
telehealth practice of interactive videoconferencing unit (Polycom, Pleasanton, California) with a video
in use at the ECU Telemedicine Center, the remote camera (Canon USA, Inc, Lake Success, New York)
audiologist in this study was able to enhance the ef- was connected as an alternate video source. The vid-
ficacy of the web-based system addressed herein.
The remote audiologist was seated in a telemedi-
cine room within ECU's telemedicine suite, which
was equipped with videoconferencing and Internet
capabilities as illustrated in Fig 3. The Polycom vid-
eoconferencing unit (Polycom Inc, Pleasanton, Cali-
fornia) provided encrypted audio and video trans-
mission between the two testing sites.
A local otolaryngology office served as the on-
site, or patient, location and included a facilitator
(graduate student), an on-site audiologist, and a pa-
tient-participant. Equipment located at this site con-
sisted of a Bluetooth-Ethernet gateway device (Pa-
rani 100, SENA Technologies, San, Jose, Califor-
nia), an OTOpod audiometer (Otovation LLC, King
of Prussia, Pennsylvania), and a Polycom videocon-
ferencing unit. The Bluetooth-Ethernet gateway de-
vice and the videoconferencing system were both
connected to the Internet via the otolaryngology of-
fice. This connection had no use of a server, but in-
stead went directly to the network. The router was a
Sonic Wall VPN (Virtual Private Network). Fig 4. Setup at testing site (otolaryngology office) with
remote audiologist having video communication from ei-
The OTOpod audiometer located on-site with the ther video source 1 or video source 3 and audio commu-
patient is an off-the-shelf product that can exchange nication from both video sources 1 and 3. 1 video-
data by use of Bluetooth telemetry, which can then conferencing desktop unit (video source 1); 2 sound-
isolated booth; 3 tripod camera (video source 2); 4
be connected to the Internet through a personal door to sound-isolated booth; 5 participant or pa-
computer (via EZURiO Bluetooth-USB adapter. tient; 6 traditional audiometer; 7 door to audiology
Laird Technologies, St Louis, Missouri) or through room; 8 facilitator.
444 Crowell et al, Audiology Telepractice in Clinical Environment
MEAN (SD) THRESHOLD DIFFERENCES IN DECIBELS BETWEEN TRADITIONALAND TELEPRACTICE
ASSESSMENT METHODS (N = 12)
Conduction 250 Hz 500 Hz 1,000 Hz
Air 6.43 2.50 2.86 2.64 2.86 2.64
Bone 2.50 2.58 2.50 3.93 7.50 5.56
eo camera was mounted on a tripod located within
the sound-isolated booth in which the patient-partic-
ipant was seated. The remote audiologist was able to
hear both the patient and the facilitator at all times.
However, only one video feed could be viewed at a
time. The remote audiologist was able to see the on-
site facilitator or ask to be switched to the alternate
camera in order for all to view the participant. Once
the video source was switched, the audiologist was
able to view and hear the participant during the as-
sessment, as well as continue to privately converse
with the on-site facilitator located outside the test-
ing booth.
Current Status. By means of this system, partic-
ipants were tested with a double-blind procedural
design. All individuals were adult patients (over 17
years of age) at the otolaryngology office and volun-
tarily consented to participate in the research study.
This study (#08-0700) was approved by the East
Carolina University Medical Center Institutional
Review Board, Each participant received a tradi-
tional face-to-face assessment of pure tone hearing
thresholds by an audiologist at the otolaryngology
office, as well as an identical assessment adminis-
tered by a remote audiologist via telepractice. In this
double-blind design, the testers at each site were not
privy to the results collected at the other site. Eor
example, the audiologist located at the remote site
did not have prior knowledge of the thresholds de-
termined on-site through traditional means.
Results collected at each testing site were com-
pared for accuracy, and the test administration com-
pletion time for the telepractice portion was also re-
ported. We are optimistic regarding the preliminary
results garnered thus far (see Table), This Table dis-
plays the mean difference (in decibels), as well as
the standard deviation, between the traditional and
telepractice assessments for all participants at each
accessed frequency. The mean differences between
the two assessments were all less than or equal to 10
dB hearing level, which is considered to be clinically
acceptable. The average amount of time required to
complete a hearing test via telepractice was approxi-
mately 7 minutes per test administration, consistent
with the time required for a traditional face-to-face
assessment. Participants are still being recruited to
determine any concerns, as well as to gather addi-
tional data from a larger sample.
2,000 Hz 4,000 Hz 8,000 Hz
5.71 3.91 4.29 3.54 7.86 4.86
1.67 2.44 10.00 6.06
DISCUSSION
This novel web-based audiology telepractice sys-
tem integrated web services with Bluetooth wire-
less telemetry and videoconferencing equipment.
Although the Bluetooth-Ethernet gateway and the
server have previously been studied,2"* two addition-
al issues were investigated when the web-based sys-
tem was integrated into a clinical environment: 1)
the simultaneous presence of the Bluetooth device
used in the audiology telepractice system with the
hearing aid programmers used in the otolaryngol-
ogy office; and 2) the bandwidth demands among
the web-based system, the videoconferencing traf-
fic, and the otolaryngology office's regular Internet
data transmission. This section discusses these is-
sues and points out the necessities of a facilitator at
the patient site.
Co-presence of Bluetooth Devices. One problem
that was encountered during testing was interfer-
ence of the Bluetooth-Ethernet gateway device used
to connect the audiometer to the Internet with the
otolaryngology office's Bluetooth hearing aid pro-
grammers. Most audiologists use wireless devices
to program hearing aids, which are an integral part
of many audiology practices. Ensuring no interfer-
ence was crucial to the feasibility of incorporating
this system. The Bluetooth-Ethernet gateway de-
vice was reprogrammed to allow connections only
to those Bluetooth addresses owned by the OTO-
pod audiometer. Even though this solution resolved
the predicament, we were forced to sacrifice system
flexibility. Before an audiometer could be connected
to the Internet during the initial setup, its Bluetooth
address had to be preprogrammed in the Bluetooth-
Ethernet gateway device.
Video Communication. The current study de-
scribed herein utilized a Polycom VSX3000 desktop
videoconferencing unit that was readily available to
the ECU researchers. All of the videoconferencing
units used were encrypted to maintain compliance
with the Health Insurance Portability and Account-
ability Act. These units are also UL 60601-compli-
ant for use in patient care environments. Site con-
nectivity for the videoconferencing unit was ob-
tained through E C U ' S network to the public Internet
and then routed through the otolaryngology office's
local network. The bandwidth for the videoconfer-
encing system was set at a minimum rate of 384 ki-
 Crowell et al, Audiology Telepractice in Clinical Environment
lobits per second and required an Internet connec-
tion separate from the web-based testing applica-
tion. This provided the remote audiologist with a
smoother, more natural view of the participant's fa-
cial and body movements.
The use of a hard-end point videoconferencing
system the described Polycom unit or one similar
is popular among many telemedicine operations,
because these systems are equipped with encryption
for the interactive video and audio transmissions.
The systems are also scalable to the infrastructure
available, but do require sufficient bandwidth to
provide clear audio and video transmissions. It is
suggested that if one is to consider providing audi-
ology telepractice services, investing in a hard-nd
point or freestanding video conferencing system
would be beneficial. On the other hand, there are
further options available, including free video and/
or audio conferencing software programs (soft end
points) and inexpensive computer cameras, "web-
cams," that can be used to provide visual and au-
dio contact. Further research needs to be conduct-
ed regarding the reliability and feasibility of these
options. Nevertheless, one must make certain that
no matter the videoconferencing system and/or net-
work connectivity chosen, it must provide sufficient
encryption and/or network safeguards to ensure sat-
isfactory privacy and confidentiality of patient in-
formation and resulting outcomes.
Internet Infrastructure. This study was conduct-
ed at a well-established university telemedicine
suite and with a well-connected otolaryngology of-
fice. Although we did experience some instances
in which the video and/or audio feed was affected
by slow transmission and breaks in audio commu-
nication, this hindrance was transitory and resolved
quickly, thus not affecting our ability to test. To fur-
ther examine possible issues due to the introduction
of the videoconferencing traffic, an experiment was
conducted whose results showed that the audiology
telepractice testing caused no concerns to regular In-
ternet usage in the otolaryngology office for com-
pletion of typical office duties (eg, uploading and
downloading images, e-mail, etc).
Few published studies in the field of audiology
telepractice have been conducted in areas with po-
tentially less-than-ideal infrastructure. Successful
examples include isolated communities in Alaska^^
and Canada (Campbell and Hyde, unpublished ob-
servations) , rural elementary schools,' ^ and a region-
al medical center.'^ One such example detailed how
certain infrastructure options were not optimal for
provision of services. Polovoy^^ described the audi-
ology telepractice applications used in the isolated
445
communities of Alaska, including the use of satel-
lite transmission to conduct teleconferencing ses-
sions. Unfortunately, satellite transmission was not
deemed ideal, because it resulted in "real-time delay,
audio problems, and networking problems."^-^^P^^^
A dedicated landline is presumed to provide better
communication functionality.
Additional research pertaining to infrastructure
requirements for the provision of audiology tele-
practice is needed for many settings, including but
not limited to military bases and/or hospitals. Veter-
ans Health Administration clinics and/or hospitals,
residential facilities, and prisons.
Facilitator. Our current study protocol made use
of an on-site facilitator. This individual, who in our
case was an audiology graduate student, was re-
sponsible for obtaining participant consent, equip-
ment setup, providing instructions, and participant
management. The facilitator was also responsible
for collecting the results from the participant's tradi-
tional audiological assessment.
Even though audiological services are being pro-
vided from a distant location through technological
applications, it is still advisable that a facilitator be
on-site with the patient. The exact role and training
level of the facilitator is an area of continuing study,
but having trained personnel at the patient site is
recommended, particularly for patient management
and placement of diagnostic equipment, ie, correct
headphone placement. Krumm et al"' also stated
caution regarding the need for knowledgeable tech-
nical support personnel.
Economic Considerations. As with any new mod-
ifications to patient-directed care, economic consid-
erations are paramount. There are concerns whether
adopting a system like that described in this article
will monetarily benefit a clinical practice. Many of
the costs incurred with the proposed remote hear-
ing assessment will be no different from those of a
standard audiometric setup. Our study indicates that
the Internet transmission required by this system is
no more than what currently exists in most office
locations, especially if digital transmission of pa-
tient data is already in use. The required facilitator
can be an existing staff member or a nursing profes-
sional with certain training. These costs are minimal
compared to those of a licensed audiologist spend-
ing crucial patient contact hours traveling to remote
clinical locations. Instead, these trained profession-
als can spend this time at the primary office seeing
more patients via telemedicine techniques. This sys-
tem can also be economically beneficial for satellite
offices of medical practitioners as a triage initiative,
in that audiologists may see patients in remote loca-
446 Crowell et al, Audiology Telepractice in Clinical Environment
tions via telemedicine and then make an educated
determination as to whether these patients would be
candidates for hearing aids, cochlear implants, or as-
sistive listening devices and make the recommen-
dation for further follow-up by patients at the audi-
ologist's home office. This system will also reduce
travel time for the audiologist and potentially reduce
the need for transportation of individuals in remote
locations if no follow-up audiological care is cur-
rently needed. Thus, the audiologist's time and ef-
forts are more efficiently utilized in providing care.
In addition, although the current model discussed
herein is not available on the market, communica-
tions with the company who holds the license for
this technology indicate that their plan is to charge a
minimal monthly subscription for this service.
Another economic benefit is patient transporta-
tion. Many patients in our communities are unable
to be transported to audiology centers because of
medical conditions or current economic status. By
use of telemedicine, the costs incurred by patients
can be minimized when initial care and follow-up
care can be provided in closer locations. This is par-
ticularly important for traditionally underserved ru-
ral regions in which hearing services might be ob-
tained only after hundreds of miles of travel.
CONCLUSIONS
This report describes an ongoing effort to provide
remote hearing assessment in a clinical setting. Is-
Acknowledgments: The authors thank the personnel at both the local office of otolaryngologists and at the East Carolina University
Telemedicine Suite for their gracious assistance. The authors also thank Alyson Butler, AuD/PhD. student in the Department of Com-
munication Sciences and Disorders at East Carolina University, for her assistance in data collection, as well as the staff at the College
of Technology and Computer Science for their assistance in maintaining the web server.
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