Teleaudiology for Pediatric Cochlear Implant Patients: A Partnership Program

Following the onset of the COVID-19 pandemic, telehealth programs have become more widespread across health care entities, including audiology.1 For cochlear implant (CI) programs, there has been an increase in virtual mapping via tablet and the use of manufacturer specific telehealth options, such as Remote Check and Remote Care.2–6 These programs, offered by Cochlear Corporation, allow for administering questionnaires, the assessment of speech understanding via a number recognition task, and minor global mapping adjustments. Unfortunately, these remote options do not adequately account for the important information that can be gained from controlled assessments of aided detection and speech recognition. As pediatric recipients may not be able to subjectively report, booth testing is vital to provide information regarding speech clarity and potential mapping adjustments needed.Table 1: Pros and Cons of a Teleaudiology Program.The Children’s Cochlear Implant Center at the University of North Carolina (CCIC) and Appalachian State University Audiology (ASU) partnered to create a telehealth program prior to the COVID-19 pandemic that incorporates two critical elements of CI care: assessment and mapping. This teleaudiology program aims to provide optimal care for pediatric CI users who live in western North Carolina. The CCIC is in Durham, and ASU is 166 miles, or a three-hour drive, away in Boone. Within the program, patients of the CCIC who live more locally to ASU are seen in-person at the ASU clinic. Aided detection and speech recognition assessments are completed by an audiologist at ASU. Patients and the audiologist at ASU join secure webchats with an audiologist at the CCIC to complete the mapping of CIs remotely. This teleaudiology program is available for recipients of all CI manufacturers. REASON FOR PROGRAM DEVELOPMENT At the CCIC, approximately 75% of patients come from over an hour away and 25% come from over three hours away. When developing our teleaudiology program, our aim was to provide care closer to home while maintaining our same assessment and mapping protocol, and quality of care. One challenge when developing a teleaudiology program is finding a way to assess aided detection and speech recognition. The partnership program allowed us to gather this information consistently and accurately. It also allowed us to have access to a trained test assist for mapping, which is important when working with the pediatric population. With alternative remote options, families are required to have a reliable internet connection and navigate connecting equipment on their own. With our program, we did not have the extra expense and liability of mailing programming tablets to patients and their families. DEVELOPMENT The CCIC began developing the program with ASU in June 2019, and the process took about four months. Set up included HIPAA agreements between institutions, legal contracts, and equipment coordination. There were several virtual meetings between the audiologists to develop a protocol and visit schedule, as well as two onsite meetings at the ASU clinic by the primary CCIC audiologist. The first joint patient was seen in October 2019. The following equipment was provided by the CCIC to the ASU clinic: programming equipment for all CI manufacturers, speech recognition test materials, and basic troubleshooting equipment. The ASU clinic supplied computers, audiometers, tympanometers, Verifit 2 for electroacoustic stimulation devices (EAS) and bimodal patients, and booth space. It was determined that each audiologist would book the patient for the same two-hour block (the standard appointment length at the CCIC). The audiologist at ASU would begin with aided detection and speech recognition assessment before logging on to the webchat. The audiologist at the CCIC would be on the webchat at the start of the appointment in case of CI equipment issues or if the family had other needs or questions. The audiologist at ASU would remain available following the aided detection and speech recognition assessment to assist the audiologist at the CCIC during mapping. PROGRAM ADJUSTMENTS Overall, pre-determined appointment flow was successful, though time consuming, for both providers. The biggest challenge was effective communication. This included scheduling visits and determining the specific assessments needed for each patient. As the program progressed, we fine-tuned our process around these areas by having both audiologists reserve time on specific days for this program. This allowed for the CCIC audiologist to schedule patients more efficiently. Both providers used administrative/research time to see these patients; we acknowledge this arrangement would not be possible at all clinics. We also discovered that the maps would need to be sent back to the CCIC to be stored in the database for map requests or other purposes. The program was adjusted so that at the end of each session the maps would be exported by the CCIC audiologist, then sent to the CCIC by the ASU audiologist to be uploaded into the central database. This helps prevent any time delays when patients need equipment. This program was found to be best for established patients who were at least six months post-activation. The patient was acclimated to booth protocols and families felt more secure in their child’s progress. MAPPING We were able to see complex cases through this program, including patients with cochlear nerve deficiency, patients with unilateral hearing loss or single sided deafness (SSD), and patients using EAS. Through this program we were able to identify an internal failure and were able to coordinate surgery without the family having to drive to the CCIC surgical center. Regular mapping techniques were used, with one exception. Currently, ESRT has not been attempted through this program due to the difficulties of incorporating the tympanometer with the virtual platform. ECAP measures, scaling electrical comfort levels, and measuring/counting electrical thresholds have been completed without issue. To complete these tasks a few modifications were made to the traditional telehealth set up. Measuring/counting electrical thresholds (or in some cases scaling comfort levels) is more difficult when patients can see the screen. In this telehealth set up, the patient is faced away from the screen with the audiologist at ASU providing feedback about responses in cases where the programming audiologist could not see them fully. For patients who have residual hearing (EAS patients) or normal/near-normal hearing in the contralateral ear (SSD patients), the computer was muted to complete any subjective mapping task. The programming audiologist would communicate through the webchat as needed and unmute the computer when finished with the task. BILLING Initially, the teleaudiology program was covered by a grant and the CCIC audiologist did not bill for services. After the onset of the COVID-19 pandemic and the expansion of telehealth coverage, the CCIC audiologist was able to bill the mapping codes (92604 and 92602) with a telehealth modifier. Throughout the program, the ASU audiologist was able to bill for the aided detection and speech recognition assessments. No telehealth modifier was needed for the ASU audiologist as services were provided onsite. With these billing practices, each provider was billing for about half of the time set aside on their schedule. This was agreed upon by clinic managers prior to the onset of the program. RESULTS Since the onset of this program in October 2019, a total of 14 patients have been seen for a total of 27 appointments. This has saved patients an estimated 3,413 miles of travel. The program was well received by patients and their families, overall. Approximately 29% of patients decided to remain in the teleaudiology program full time, with the remaining patients choosing to participate part time while coming into the CCIC part time. Both participating clinics, the CCIC and ASU, have found this to be a productive program that provides an option for patients who live far away. A summary of the pros and cons of the program can be seen in Table 1. We acknowledge that this type of program would not be possible for every clinic. Both participating clinics are university clinics that allow the providers to have dedicated research/administrative time. This gave both audiologists dedicated slots for telehealth, allowing for easier scheduling and co-ordination. In addition, as both clinics are part of the North Carolina University system, the legalities and contracts processes were more straightforward. The final factor of success was that the two audiologists were motivated to collaborate in the care of these patients. Communication between the audiologists was essential to refine this program and provide appropriate care for patients and families. Thoughts on something you read here? Write to us at [email protected].