eEHDI: evolution to revolution

Bill Campbell, MCISc

EHDI 2019 Lunch & Learn

• eAudiology: Shifting from Theory to Practice

• Practical approaches to teleaudiology for infant hearing programs

• Transitioning an infant hearing program to Integrity™

• Establishing a standard ABR assessment protocol

• Risk monitoring via teleaudiology for delayed onset hearing loss

• Remote ABR assessment protocol demonstration

Learning Agenda

Tele-Audiology

Tele-Medicine

eHealth Health and medical care with new technologies

» Francois Julita

Tele-Audiology

Tele-Medicine

eAudiology Hearing healthcare with new technologies

» Francois Julita

eHealth

eEHDI

» Bill Campbell

Hub site: This is where the assessing audiologist is located.

Equipment necessary for establishing the telemedicine and data connection.

Spoke site: This is where the infant is located.

ABR, otoscope, OAE equipment location

Trained technician and intake staff

TERMINOLOGY

A bit of history

Ontario Infant Hearing

Program (IHP)

Began in 2001. 35 ABR audiologists.

Provides universal screening, assessment, communication

development services.

87 (42 ABR) IHP certified audiologists sited in 12 regions

across Ontario.

3 Designated Training Centers (DTC) across Ontario.

1

2 3

6

8

Central West Region

4 Peel/Halton/

Waterloo Region/

Wellington Dufferin

Southwest Region

1 - Essex/Kent

2 -Thames Valley/ Lambton /

Grey Bruce /Huron Perth

E - Central East

Region

6 - Simcoe/ Muskoka

Parry Sound

7 York/Durham/

Haliburton, Kawartha

Pine Ridge

North Region

10Sudbury-Manitoulin/ Cochrane/

Nipissing Timiskaming /Algoma

11 Thunder Bay

12 Kenora Rainy River

12

11 10

7

9

4 5 Toronto Region

5 - Toronto

F - East Region

9 Ottawa/Renfrew/

Eastern Ontario

8 Kingston/

Lanark/Leeds/Grenville /

Hastings Prince Edward

Central South Region

3 Hamilton-Wentworth / Brant/

Niagara/ Haldimand Norfolk

• Infants missed at hospital before

discharge

• Infant who refer at Stage I and do not

return for Stage II

• Infants who refer from Stage II and do not

return for assessment

Loss to follow up

• Infants missed at hospital before

discharge

• Infant who refer at Stage I and do not

return for Stage II

• Infants who refer from Stage II and do not

return for assessment

Loss to follow up

Probability of HL

0.00%

10.00%

20.00%

30.00%

40.00%

Prevalence in

General

Population

Prevalence in

WBN refer

population

Prevalence in

NICU refer

population

» Hyde, Campbell, 2010

2006: Barriers to access to IHP ABR services in northern Ontario

2008: Technology became available

Online services accessed

Development of pilot for province wide program

2008-2011: Integrated into clinical schedule

OPPORTUNITY

FEB. 2008

FEB. 2018

eEHDI CHALLENGES Then (2008) Now (2019)

Technology, connectivity Very limited bandwidth Ubiquitous telecommunications

Better bandwidth, more universal

access

Stakeholder Support or buy in Skeptical, fear of technology

Positive attitudes, but still limited in

experience and willingness

IT staff resistance

Competency Competent, but unaware Increasingly tech-savvy

Training and Setup Pioneer, trial and error Training based on evidence.

Easy setup, facilitated by equipment

design.

Privacy and Security

HIPAA Limited. Very little HIPAA compliant solutions

Encryption

Several free or inexpensive options

available

Licensure License to practice at spoke site No change

Reimbursement Too new to establish billing Minimal change

Cost Conferencing, technology more

expensive Simple technology consumer

solutions; more options

Clinical evidence Pilot programs More clinical evidence, quantitative

and qualitative data

Ongoing research

Quality of service Often limited by bandwidth Technology changes have

significantly improved quality

Infrastructure, technical limitations Several barriers with existing

technology Technology is essentially unlimited.

Human/policy barriers

2008

2019

Practical approaches to

tele-audiology for infant

hearing programs

eEHDI toolkit

Are you ready?

• Be sure it’s right for your program/clinic

• Agency mission/vision, goals

• Capital expenses

• Key people

HOW TO: A Guide

Ballachanda, B., 2017

Reimbursement?

• How will you get paid for this service?

• Private providers vs funded providers

• Wisconsin!!

HOW TO: A Guide

IT

HOW TO: A Guide

Audio/Video solution

Desktop Sharing solution

OTN PCVC

Allows for secure

access from a host

computer to any other

computer with

internet access

200 telemedicine

networks serving 3500

sites

Software Solutions Pros Cons

Telemedicine Network Encrypted, secure portal.

Technical support

Can be flexible with PCVC

Easy access from all sites

License fees, number of hub sites

Bridging to other networks

Can be limiting in site availability

Can be complex

Skype for Business Simple access

Minimal cost

Ease of use

Very flexible in terms of sites

HIPAA compliant

Need BA with Microsoft

Need agency Office 360 license

Hub site needs to be associated with

agency license

WhatsApp Claims to be encrypted, but not sure if

HIPAA compliant

Free app

HIPAA compliant?

Both hub and spoke need app

Zoom HIPAA compliant

Large single PCVC type network

Expensive, ~2000 annually,

depending on hub sites

Other options Can be inexpensive

Vary in flexibility

Check HIPAA compliance

May be expensive

Teamviewer Minimal cost

Preloaded with Vivosonic

Easy to use

HIPAA compliant

Need to ensure unattended access is

not enabled

Frequent updates

License fees

IT policy restrictions

AnyDesk Minimal cost, or free

Easy access

HIPAA compliant

License fees may apply

Other options Huge array of options available May not be HIPAA compliant

Licence fees may vary

Remote ABR assessment

protocol demonstration

Equipment

• EHDI program standard protocols

• Webcam, mic, audio

• Flexibility, technology changes!

• Shipping equipment to spoke sites

• Spoke site equipment updates

• Test, test, test

HOW TO: A Guide

Hub site:

• Audiologist

• HIPAA compliant space

• PC, preferably with dual monitors

• Webcam, mic, headset

• Teamviewer

• Videoconference solution

HOW TO: Assessment

Spoke site:

• Trained technician

• HIPAA compliant space

• Laptop or PC for ABR, with dual monitor

• Webcam, speakers, mic

• Sufficient internet connection

• Teamviewer

• Videoconference solution

• Ambient noise

HOW TO: A Guide

Spoke site Technician:

• IHP uses AABR screeners

• RN, CDA, other related professional

• In person session to setup equipment and prep

infant

• Training support and videos

HOW TO: A Guide

Training videos

Ambient Noise:

• Electrical and Acoustic

HOW TO: A Guide

Minimum Permissible Ambient Noise Levels for ABR testing with insert earphones.

125 to 8000 250 to 8000 500 to 8000 125 to 8000 250 to 8000

125 24 30 39 59 67 78 64 103

250 16 16 25 53 53 64 50 89

500 11 11 11 50 50 50 36 75

1000 8 8 8 47 47 47 33 72

2000 9 9 9 49 49 49 34 74

4000 6 6 6 50 50 50 31 75

8000 9 9 9 56 56 56 34 81

500 to 8000 500 to 8000 500 to 8000

Maximum Permissible Ambient Noise Levels (MPANL) if Testing to 0 dB HL (ANSI S3.1) MPANL if Testing to 25 dB eHL

Ears not covered Insert earphones Ears not covered Insert earphones

» Scollie, Susan, 2016

Establishing a standard

ABR assessment protocol

Standard Protocol

Protocol:

• Screening protocol

• 2018.01 ABRA Protocol

• Audiometric Assessment for Children 6-60

months (2018.01)

• Amplification protocol

• Communication Development protocol

• DxLink protocol, pending

ONTARIO

IHP:

DxLink

• More than just remote assessment

• Allows for clinician support, second

opinion, equipment checks, audits

• Connects IHP clinicians

ONTARIO

IHP:

ABR protocol

• Very specific steps – efficiency

• No identifying data on ABR equip.

• Results stored in infants “home” file

• Kept as screenshots, or exported

data file

ONTARIO

IHP:

Communication of Results

• Telemedicine model allows for immediate or delayed communication

• IHP protocol prefers delayed communication, but at clinician’s discretion

ONTARIO

IHP:

Data, Data, Data

• Central database capable of tracking

infant from screening to discharge

ONTARIO

IHP:

Transitioning an infant

hearing program to

Integrity V500 System

Transition

to

Vivosonic:

2001-2013: BioLogic NavPro

protocol

2016: purchase of 32 Vivosonic

units

2016-2018: Protocol

development

Next

Steps:

Questions?

Bill Campbell

bill@superiorhearing.ca