Tele-audiology has created quite a buzz in the industry ever since Dr. Gregg Givens coined the term in 1999 in reference to a system being developed at East Carolina University. Considering the challenges hearing care professionals currently face due to the COVID-19 outbreak, there hasn’t been a more reasonable time to consider remote hearing care options. 

Below are some best practices and steps to consider when implementing tele-audiology for in-home patient appointments and remote office applications.

Set-up scenarios for In-Home Patient Appointments

Step 1: Identify Your Clinic’s Current Interactive Equipment

Remote Programming Apps:

1. Leading hearing aid manufacturers such as Phonak, Resound, Signia, Starkey, and Oticon offer remote hearing aid programming apps for smartphones. If you’ve yet to explore these apps, now is a good time to learn about the ways in which they can benefit you and your patients. 
2. Process
3. 1. Have patient download appropriate app on their smartphone
   2. Obtain patient’s email address and register on manufacturer’s website (if necessary)
   3. Provider has access to website, a desktop/laptop, and headset and/or webcam 

Desktop or Laptop with Windows 10 OS, Internet Connection, and Email Capability

Smartphone or Tablet

Other

1. PC monitor
2. Webcam with access to audio (microphone and speaker)
3. Headset with boom mic
4. A practice management system with atelehealth connectivity feature (Sycle, CounselEAR, BluePrint, etc.), or, anon-public facing audio/video platform.A non-public facing remote communication product is one that, as a default, allows only the intended parties to participate in the communication, such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, WhatsApp video chat, Zoom, Skype, etc.

Step 2: Identify Your Patient's Current Equipment and Needs

Home Video Chat Appointment:

1. Smartphone or tablet
2. Desktop or laptop with access to a webcam, microphone, and speaker
3. Have appropriate hearing aid manufacture’s app already downloaded or need to download it or another A/V platform app

Step 3: Identify Patient's Desire for Home Video Appointment

The below example is of a front office staff (FOS) interviewing a patient for initial “triage” appointment. Here’s a basic script you can follow:

FOS:Good morning, how may I assist you today?

Patient:I am having problems with _____________________

NOTE: Pending patient’s response, FOS may be able to assist with issue over the telephone. If the FOS determines the patient requires more comprehensive assistance, proceed to next questions.

FOS: With today’s concern about COVID-19, we are using technology to provide you services.This will protect you and reduce your exposure to other people.Would you like an in-home video appointment with your provider?

Patient:Oh, yes.If I don’t have to come into the office, that would be wonderful.

FOS:Great!May I ask you some questions about the types of technology available to you at home?

1. Do you have a smartphone? If yes, what type?Are you familiar with usingvideo chat, email, texting, and web browsers on your phone?
2. Do you have a tablet, such as an iPad?If yes are you familiar with using video chat, email, and web browsers on it?
3. Do you have adesktop computer or laptop? If yes are you familiar with using video chat, email, and web browsers on it? Does it have a webcam, microphone, and speaker?

After gathering this information, the FOS should use the grid below to determine if the patient should be scheduled for a telephoneappointment or an audio/video appointment. 

NOTE: It's recommended that a spouse or other third party attend the appointment as communication through this environment can be challenging for the hearing impaired.

Patient Says Yes To	Uses it For	Appointment Type
iPhone and/or iPad	Facetime, Email	Audio-Video Appointment via Facetime
Android phone/tablet	Email, Internet Search	Audio-Video Appointment via video chat platform
Smartphone and/or Tablet	Phone, Text, Pictures	Telephone Appointment
Desktop and/or Laptop with webcam, microphone and speaker	Email, Internet Search	Audio-Video Appointment via platform
Desktop without webcam, microphone and speaker	N/A	Telephone Appointment

NOTE: Following the telephone or A/V appointment, the patient may need an appointment for in-office programming services at provider's discretion.

NOTE: Using a smartphone or tablet for this communication will drain the device's battery. Please inform the patient to have their device fully charged or charging for appointment.

Step 4: Completing the Patient-in-Home and Provider-in-Home Appointment

Initial Telephone/AV Conferencing (Facetime, Skype, etc.)

Front Office Staff Tasks:

Identifies patient’s specific need through telephone interview (sample above) and may be able to guide patient through basic troubleshooting without additional appointment.

A. Charger is not working:

1. Ensure hearing aids are in the correct cradle and in the correct direction
2. Ensure charger is plugged into outlet

B. Hearing aid is dead/noisy/weak:

1. Clean receiver end and microphone with brush
2. Change battery pill
3. Check if battery charger is working
4. For dome or filter changing instructions, arrange for provider to call.Provider may attempt to explain steps over phone, but may do better with a video consultation.

Provider Tasks:

Either telephone or video conferencing at provider’s discretion and patient’s equipment availability.

1. Hearing aid new fit follow-up (discussion and review of use and maintenance, etc.)
2. Six-month checkup (identify any current needs, review, maintenance, etc.)
3. Dome or filter changing
4. Insertion orpainissues
5. Volume or programming control manipulation concerns
6. App downloads for use of volume and basic program options
7. Sale or instruction of new assistive devices for TV, remote mics

Step 5: Completing the Patient-in-Office and Provider-at-Home Appointment

In-office programming by remote provider through video conferencing platform (Skype, Zoom, etc.). Uses an on-site staff member as “Facilitator” to assist remote provider with patient sitting near computer and manipulating programming equipment.

Examples of Applicable Scenarios:

1. Amplification clarity or noise comfort issues
2. Volume or programming control changes
3. General hearing aid preferred settings
4. Activate acclimatization (if applicable) feature
5. Add or remove programs due to newly identified hearing need

Set Up:

1. Train facilitator on connecting hearing aids to programming device (different methods for different types of hearing aids and manufacturers)

2. Provider in off-site/remote location with laptop or desktop (phone/tablets do not work)

1. Instruct facilitator on how to connect hearing aid to appropriate programmer
2. Install remote access A/V platform. Be sure computer's volume and camera is activated.
3. Activate the microphone and video camera in the A/V platform.
4. Use telephone/cellphone to communicate with office facilitator and patient if microphone not available on desktop
5. Video use through laptop or desktop camera is ideal,butoptional

3. Patient in clinic where hearing aid programming software and facilitator is located

1. Install remote access A/V platform onto desktop with programming software
2. Use telephone/cellphone to communicate with remote provider if microphone not available on desktop
3. Video use through desktop camera is ideal, but, optional

Patient Interaction:

1. Facilitator initiates remote access by inviting provider to conference
2. Provider accepts invitation
3. Facilitator selects “Share Screen” (or similar command) so provider can view clinic’s programming screen
4. Facilitator selects “Give Control” (or similar command) so provider can manipulate keyboard and mouse of clinic’s programming computer
5. Facilitator and provider connect via audio through computer mics or telephone/cellphone
6. Facilitator sits patient in front of programming computer and monitor
7. Facilitator introduces patient to provider via audio interaction explaining that even though provider is in another location, provider is very capable of making appropriate adjustments to hearing aids as needed
8. Provider acknowledges patient and assures appropriate care will be given even though provider is not physically in the office
9. Consultation between provider and patient commences via audio communication in a typical manner to identify patient’s need
10. Provider instructs Facilitator to connect hearing aids to programmer
11. Provider manipulates computer software (NOAH, manufacturer software, etc.) in usual manner
12. Provider makes programming changes in usual manner
13. Provider may use Facilitator or third-party (if applicable) as an onsite voice tester to confirm changes were applied and an improvement was made as expected
14. Conclude appointment with usual salutations
15. Make follow up appointment for further programming or telephone follow up as needed