The current scoping review identified 32 papers that satisfied the inclusion criteria in tele-audiology (Figure 1).
A summary of the literature reviewed based on the scoping review’s inclusion criteria was tabulated for analysis. The study code, study title, authors, countries, and focus area are all listed in Table 1a (additional file 6). Table 1b (additional file 6) describes the settings, participants, employees, and types of services.
Studies describing similar background content in the introduction, common implementation sites, broad objectives, and a contiguous group of investigators were mapped as a single project. This exercise was undertaken to make a realistic assessment of the implementation focus. Studies were considered independent projects when they could not be mapped under any other larger project. Twenty-one projects were identified based on this mapping exercise (Table 1) and each project was coded as P (project) and serial number, for ease of reference. The subsequent findings will be reported using these project codesGeographical distribution of projects
Tele-audiology was implemented in 12 projects in the United States of America (USA); two projects in Australia; three projects in India; two projects in Canada; one project each from Poland and South Africa. Projects implemented in almost all the countries (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P14, P16, P18, P19, P20) were delivered to overcome access barriers for individuals in rural areas and/or remote locations. However, in the US there were few projects (P11, P12, P13, P15, P17, P21) that provided tele-audiology services even to urban and semi-urban areas due to scheduling related issues (work, having other children to take care of, household responsibilities).
Focus area of service delivery
Tele-audiology was implemented in projects with a focus on ear and hearing screening, diagnostic audiological evaluations, a combination of diagnostic audiological with otorhinolaryngological evaluation, hearing aid fitting and programming, cochlear implant fitting and mapping as well as intervention services.
Mobile phone-based ear and hearing screening was carried out among school-aged children (P1). Telepractice was used to conduct diagnostic confirmation of hearing loss among infants in follow-up to hearing screening (P2; P3; P4; P5; P6). Tele-auditory brainstem response (ABR) and tele-distortion product otoacoustic emissions (DPOAEs) were performed in all these projects. Other diagnostic tests such as immittance including high-frequency tympanometry and middle ear muscle reflexes, and Auditory Steady-State Response (ASSR) were included only in a few projects (P2, P3).
Diagnostic audiological evaluation combined with otorhinolaryngological evaluation using telepractice was reported in four projects (P7, P8, P9, and P10). In these projects, basic ear (video-otoscopy) and hearing testing (audiometry and tympanometry) was provided as a routine service to individuals of all age groups.
Remote hearing aid fitting, verification and programming (P11, P12) as well as remote cochlear implant switch-on and mapping (P14) were conducted for all age groups. One project focused on cochlear implant mapping for geriatric patients alone (P13). In the projects where remote cochlear implant switch-on and mapping were conducted (P13, P14), tests such as acoustic reflex threshold/neural response telemetry/ neural response imaging and e-stapedial reflex threshold was carried out through telepractice.
Telepractice was used for aural re/habilitation of both children and adults (P15, P16, P17, P18, and P19) to provide auditory-verbal therapy or some form of habilitation training to individuals with hearing loss.
Comprehensive audiological services to individuals of different age groups were provided with tests including audiometry, hearing aid fitting and programming, cochlear implant fitting and mapping in one project (P20). On the other hand, another project (P21) conducted only hearing screening and hearing aid reprogramming using telepractice, for adults. The diagnostic confirmation and hearing aid fitting was done in person.
Method of telepractice
Use of synchronous/real-time, asynchronous/ store and forward, or a combination/ hybrid method for providing tele-audiology services was identified from the scoping review.
In tele-audiology, the asynchronous method of service delivery was predominantly used for audiometric screening, video-otoscopy, and tympanometry (P1, P7, P8, P9, and P10). Client details, video-otoscopic images, and audiometric or tympanometric data were stored and forwarded to an audiologist or otolaryngologist for review. For tele-diagnostic evaluation of hearing among infants, synchronous methods (for both ABR and DPOAEs) or hybrid methods of synchronous (for ABR) and asynchronous (for DPOAEs) were used (P3, P4, P5, P6). In one project (P2) all diagnostic tests (video-otoscopy, middle ear analysis, DPOAEs, ABR and ASSR) were completed synchronously. Remote hearing aid fitting and programming (P11, P12, P20, and P21) and remote cochlear implant fitting and mapping (P13, P14), were conducted synchronously. In one project (P12), even real-ear probe measures were conducted synchronously. Aural habilitation services like Auditory Verbal Therapy (AVT) were provided synchronously (P15, P16, P17, P18, and P19).
Model of telepractice service delivery
When an e-helper/telepractice assistant/ support staff supported patient care, it was categorised as “professional-facilitator-patient’ model; when the professional delivered the service directly to the patient without intermediary personnel, it was categorised as ‘professional-patient’ model; and ‘professional-professional’ model involved a second audiologist or any other professional at the patient site.
In tele-audiology, irrespective of test procedures, the ‘professional-facilitator-patient’ model was used whenever services were provided to remote rural areas. In this case, a trained e-Helper/telepractice assistant/community-based health worker served as a facilitator for telepractice (P1, P2, P3, P4, P5, P6, P8, P9, P10, P11, P12, and P20) and their roles were defined in the project. This was the most commonly used model of telepractice service delivery. The ‘professional-patient’ model was predominantly used for services provided through video-conferencing such as AVT and habilitation of individuals with hearing loss (P15, P16, P17, P18, P19, and P21). The ‘professional-professional’ model was used for fitting cochlear implants (P13, P14) when both audiological and otorhinolaryngology services were provided (P7). The professional at the patient’s end was an audiologist with no specialised training in cochlear implant aural rehabilitation, while the professional who provided services via telepractice was specialised in this area (P13). In one project (P14), a speech therapist was the professional available at the patient end to facilitate the telefitting of cochlear implants. Otolaryngology consultations were supported at the patient end by a variety of professionals including audiologists, physicians, public health nurses, dentists, and physician assistants, as a part of a routine telemedicine clinic (P7).
Implementation Barriers and Facilitators
Out of the identified projects in tele-audiology, 14 projects (P1, P2, P3, P4, P5, P7, P9, P10, P11, P13, P14, P18, P19 and P20) reported service delivery to be ongoing or routine. The rest, even though long-term, were still in the research phase.
Tele-audiology services were implemented in a more sustained manner in hearing screening programs for infants. For example, follow-up diagnostic evaluations were conducted using telepractice in the USA and Canada (P2, P3, P4, P5), ear and hearing screening among school children was conducted in the USA (P1) and diagnostic audiological with otorhinolaryngological evaluation for adults was conducted in the USA and in India (P7, P9, P10). The Veterans hospitals in the USA have implemented remote hearing-aid fitting and programming as well as cochlear implant fitting and mapping as a routine service (P11, P13, and P20). Another effort is the National Network of Teleaudiology in Poland for cochlear implant switch-on and mapping (P14). Aural rehabilitation has also been implemented in a sustained manner in both the USA and Australia (P18, P19).
The factors that influenced implementation positively (facilitators) and negatively (barriers) are reported based on the combined results of the scoping review and thematic analysis of SSI. The combined data could be identified under three domains: patient/ caregiver related aspects, organisational aspects, and ethical-legal aspects. The quotes are summarized in table 2 under the respective overarching themes.
Patient/ caregiver related aspects
Parents were hesitant to adopt tele-audiology in the beginning as they were apprehensive about the child's ability to build rapport with the therapist. In such a case, they were given a choice of a combined approach of in-person and telepractice sessions until they felt comfortable and confident (P5, P19) or visiting in-person for the sessions till they wanted to explore telepractice sessions (P15, P18). The families were provided with the opportunity to meet the therapist and participate in a practice video conference session before the commencement of telepractice sessions. Such a mindful approach was found to help address patient apprehensions (refer to quote 1). Parents also became ambassadors of the program when they saw the value in it (refer to quote 2).
Patients' or caregivers' perceptions and understanding of the advantages of tele-audiology service delivery was a key facilitator (P5, P7, P8, P14, P15, P19, and P20) (refer to quote 3). Continuous and ongoing engagement with communities in a culturally safe manner and building awareness regarding the service enhanced acceptance (P1, P8) (refer to quotes 4 and 5). Reduced travel cost associated with tele-audiology services was perceived as facilitatory for implementing such services (P12, P14). Real-time presence of the professional, technical team and support staff and reassurance by them, facilitated the acceptance of tele-audiology by patients/ caregivers (P15, P18, P19, and P20). Patient’s acceptance of technology use in ear and hearing care improved when visual images of tests conducted (image of tympanic membrane) were provided (refer to quote 6). Acceptance was also conditional to the absence of any direct cost to the patient (refer to quote 7) or in case of subsidised service (refer to quote 8). Patients felt secure when data security, privacy and confidentiality were protected (P5, P16).
Participation in tele-audiology sessions by other family members, who otherwise would not be able to do so, was further reassuring in some instances (P15, P19). However, program implementers felt that the assessment of a patient’s suitability for tele-audiology was crucial and it was important to clearly communicate to the patient when telepractice might not be the best option (refer to quote 9). Setting appropriate expectations for the patient and ensuring clear communication prior to telepractice service delivery can enable acceptance (refer to quote 10).
Continued support from the organisation is crucial for sustainable telepractice service delivery. Adoption of new service delivery requires change and this change needs to be supported and driven by the leadership with a vision for sustainability (refer to quote 11). Organisations see value in telepractice because of their threefold advantage: teaching, research and service delivery (refer to quote 12).
Higher initial capital investment to set up tele-audiology service delivery and the need for specialised equipment to support such practice was reported as a barrier to implementation (P6, P12, P15, and P20) and was only possible with adequate funding (refer to quote 13). When there was a pause or temporary issue with the release of funds, it adversely affected service delivery (refer to quote 14). Even though tele-audiology has gained popularity and preference in the pandemic, it was not adequately supported financially by organisations in the past for routine service delivery (refer to quote 15). Multiple sources of funding including scientific grants, organisational funding, and charitable donations were required to ensure continuity of service (P19, P20) (refer to quote 16). On some occasions, lack of insurance reimbursement for tele-audiology services was a barrier (P11) (refer to quote 17).
When long-term cost outcomes or cost benefits of tele-audiology were evaluated they found it to be a beneficial alternative from a societal perspective (P10, P15). Considerable efforts were taken to establish and self-sustain billable tele-audiology service delivery and these were very few (P21) (refer to quote 18).
The lack of interlinking support structures across administrative health authorities is detrimental to sustainability (P5). Assessing needs, availability of internal resources, financial planning and a service delivery model that is flexible and adaptable to change was considered useful (P9, P20) (refer to quote 19). Systematic pre-implementation feasibility, test runs and validation of functional requirements were also other useful components of sustainable implementation (P9, P5, and P18). Formulating a Memorandum of Understanding (MOU) and a Telehealth Service Agreement (TSA) before implementation was reported to be facilitatory (P5, P11). Integrated electronic health records were also recommended to ease telehealth service implementation (P7, P20).
Limited or non-availability of professionals and technicians trained in tele-audiology service delivery was reported to be a major barrier (P15). Retention of personnel employed in tele-audiology service delivery was a challenge as it was perceived to be labour-intensive (refer to quote 20). The uniqueness of telepractice draws personnel to work in such services; however, continuity is supported by monetary benefit, opportunities for career development and positive outcomes of services (refer to quote 21). Hesitancy among service providers to adopt tele-audiology was another challenge (refer to quote 22). This could be due to a fear of change, and/or lack of training and expertise in telepractice service delivery which could affect long-term implementation.
In providing remote care, establishing a local “point of contact” who is dedicated and committed to assisting telepractice service delivery was beneficial (refer to quote 23). Having a liaison from the community helped minimise and overcome cultural barriers (refer to quote 24).
A dedicated team including professionals, and administrative and technical support staff was considered pertinent (P6, P19) (refer to quote 25). Reliable patient outcomes were associated with team-building, coordination and streamlined communication between all collaborators involved in telepractice service delivery (P5, P11, and P13) (refer to quote 26). Further, defining the roles and responsibilities of e-helper/ telepractice assistants with systematic culture-sensitive training was considered useful (P7, P20) (refer to quote 27).
Equipment and infrastructure:
Devices with a simple user interface, minimal skill requirement, display in local language and adequate battery back-up were essential to support remote community-based tele-audiology services (refer to quote 28).
Poor internet bandwidth compromised service delivery in rural areas (P10, P15, P17) (refer to quote 29) and the use of undersea cables and broadband connections were regarded as more reliable (P5, P19) (refer to quote 30). High quality dedicated video conferencing equipment was a quality enhancer in tele-audiology service delivery (P14, P19, P20). In rural areas where issues in connectivity were expected, the store and forward method of tele-audiology was found beneficial (refer to quote 31).
Capitalising on available resources (patient’s own devices, pre-existing infrastructure) facilitated seamless implementation (refer to quotes 32 and 33). Contrary to popular belief, digital proficiency was not reported to be a significant barrier, as it was felt that a supporting mechanism can be created (refer to quote 34).
Lack of acts, laws, malpractice liability and credentialing issues were some of the reported barriers (P11). In certain countries where state licensing was essential, unique licensing policies to deliver telepractice services across states was required (refer to quote 35). Some of these legislative policies gained popularity only after the COVID-19 pandemic and program implementers felt that these changes need to be made permanent (refer to quote 36).