Connecting to Communicate: Defining Telepractice

Introduction and Overview

This is the first course in a three-part series on telepractice entitled "Connecting to Communicate". Your participation today tells me that you are interested in exploring the possibility of telepractice for yourself or for your workplace, whether that be a school, a hospital or clinic, or any other setting in which you practice. I am excited to share more with you on this emerging topic.

In this course, we will define telepractice as a service delivery model within speech-language pathology. Currently, there are many changes occurring with regard to how service delivery is being shaped, not only within speech-language pathology but also within healthcare and education. These changes continue to push us toward more telepractice service delivery models across disciplines. 

Digital Disruption

Digital health can be defined as the use of information technology and electronic communication tools, services and processes to deliver health care services or to support or facilitate better health. Within the United States, digital health is a huge money maker. Current estimates indicate that digital health grosses $250 billion annually, with a projected annual growth of 10-25%.

There are many individuals who resist this advancing and evolving technology and would prefer that it would either slow down or stop. In other words, they would like to see this "digital disruption" come to an end. Digital disruption is the change that occurs when emerging digital technologies and business models impact the value of existing goods and services offered in the industry. The term "disruption" is used because these new digital products and services disrupt the current market and cause the need for re-evaluation. However, as much as we want to remain undisrupted, we know that technology will continue to change and to shape what we do and how we do it. In fact, digital health has a significant positive impact on many aspects of healthcare, including reducing costs related to patient hospitalization and patient support and allowing employers to reduce medical staff by using telehealth platforms and services.

In terms of digital disruption, we see a lot of changes occurring in the healthcare landscape. Mobile health (mHealth) is the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research. There are countless apps available for use on smartphones and tablets that can be used for health-related purposes such as fitness tracking, monitoring heart rate, monitoring glucose levels, and even to make sure that you are drinking the right amount of water every day. Another aspect of digital disruption is 3D printing. This technology is capable of creating prosthetic body parts, such as limbs and ears. Advances in 3D printing are on the cusp of allowing researchers to create new tissue, and even to generate new organs. There are virtual and augmentative reality applications being used to rehabilitate and reorient people who have had strokes. Increasingly, we see the use of robotics and artificial intelligence being used in healthcare, including surgical applications. Of course, social media and social networking both have the ability to connect people with different healthcare needs, to their provider, and to other individuals with whom they can share information. In addition, "smart" technologies continue to evolve. Now, many of us have not only smartphones, but also smart cars and smart homes. Of course, within this context of digital disruption, we have the service delivery models of telehealth, telemedicine, and telepractice.

Trends Shaping the Future of Healthcare

Many emerging technological trends are shaping the future of healthcare. The trends we will be looking at may seem crazy and outlandish, but this is the type of research that is happening right now in the healthcare industry. Ideas that years ago would have been considered science fiction are now being tested, perfected and implemented for medical applications. More research is needed for some of these techniques, but the results are promising.

• Robots (controlled by humans) are being used in different surgical procedures. In some cases, the surgeon may be miles away, perhaps even on another continent, controlling the robot remotely. In the future, robots will become much more integrated into surgical teams, as already established in the area of radiotherapy.
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• The area of genomics is relatively recent. We are now able to map a person's genome: the complete set of genetic material present in a cell or organism. Using this technology, we are developing the ability to personalize healthcare. If we can create medications based on a person's unique genome, they would more precisely target what may be wrong with that specific person, instead of using medications that are developed over hundreds of patients. In the future, DNA analysis will become a standard step when prescribing medicine or treatment, to ensure it is personalized and optimized for an individual's metabolic background.
• The use of body sensors is becoming more integrated into healthcare. Technology is allowing us to measure critical health parameters in convenient and inexpensive ways.
• Star Trek fans are familiar with the tricorder, a handheld device used on the popular science fiction show to scan the environment to obtain and analyze data. Similarly, medical tricorders are being developed which will be able to quickly and inexpensively scan a person's body in order to diagnose medical conditions. Diagnostic procedures are shifting towards devices that are portable and able to be performed from home.
• Rehabilitation robotics support an effective and efficient way to treat patients through a state-of-the-art therapy.
• Therapeutic electrical stimulation, the use of electrical energy as a medical treatment, continues to evolve. Those of you who work in the area of hearing loss, cochlear implants electrically stimulate the auditory nerve. There is work being done where they stimulate the spine to enable a paralyzed person to use their limbs again.
• More and more in the healthcare industry, we are seeing health being "gamified". Combining fun and games into healthcare can motivate the patient and collect data needed to make informed decisions on daily activities that contribute to one's health. 
• We have begun to see do-it-yourself (DIY) biotechnology. Cheaper technology and a DIY spirit are creating a new generation of scientists and engineers who see no limitations in research. Community biology labs are popping up around the world. The resulting innovation in biotech has the potential for disruptive solutions that will further change the way medicine is practiced.
• The area of 3D printing is being revolutionized in many ways, specifically with regard to health care and medical applications. In the future, we may be able to analyze a person's DNA, and use material (either synthetic or tissue cloned from the body) to 3D print new tissue or a new organ (e.g., a lung or a liver) so that the person's body wouldn't reject that implant. In the future, we will rely more on 3D printers to manufacture medical equipment, prostheses or even drugs.
• We are seeing exoskeletons and prosthetics being used that are reminiscent of the movie "Iron Man". These exoskeleton suits have enabled partially paralyzed individuals to walk again.
• Increasingly, patients are becoming empowered to use technology to diagnose themselves. The internet has led many people to research their symptoms online and to diagnose and treat themselves. People can also use discussion groups and chat rooms to share symptoms and create support groups with other people who have the same conditions or diagnoses. 
• Telemedicine and remote care are becoming a more popular and essential component of healthcare. Home health care services and innovative technology will allow for doctor-patient connectivity.

All of these trends will drive us to rethink the medical curriculum. With so many technological advances, we need to be aware of the phenomenon known as digital Darwinism, which is defined as the evolution of society and technology and its impact on behavior, expectations, and customs. Digital Darwinism occurs when technology and society evolve faster than an organization or entity can adapt. Digital Darwinism is a fate that threatens most organizations in almost every industry, including healthcare. As SLPs, we continue to see how technology is changing our behavior and the way we provide service.

As a professor at a university, these technological advances also make me rethink how we're training the next generation of speech-language pathologists. We want to make sure our students have experience with telepractice so that when they leave the classroom and enter the workforce, they are already familiar with and not intimidated by the telepractice process. Going forward, medical schools will prepare future physicians, SLPs and audiologists for a world full of e-patients and technology.

Telehealth, Telemedicine, and Telepractice

Now that we've taken a broad view of what's happening with digital health, I want to start focusing more specifically on telehealth, telemedicine, and telepractice.

The telehealth market is changing healthcare. By 2021, it is expected that the telehealth market will reach 9.35 billion dollars, up from 2.78 billion in 2016. By 2025, it is estimated to reach 113.1 billion dollars (data obtained from https://www.marketsandmarkets.com/PressReleases/telehealth.asp).

Here are some compelling statistics that demonstrate how the healthcare landscape is changing with regard to telehealth, and how it can benefit patients and providers alike (Wood, 2016):

• More than 70% of employers plan to offer telehealth/telemedicine services as an employee benefit.
• 65% of Americans reported they would attend an appointment via video telehealth.
• 90% of healthcare executives said their organizations have implemented or are developing telehealth programs.
• Nearly 75% of all physician, urgent care, and emergency room visits classify as unnecessary or could be managed by phone or video. Think about the cost savings that could result if physicians were able to spend time treating the most critical patients instead of handling minor situations (e.g., strep throat or pink eye).
• About 60% of primary care physicians (PCPs) are willing to hold appointments with patients via video.
• The nearly 20% of Americans residing in rural areas stand to benefit from telemedicine services, as they live far away from most providers.

Digital Natives vs. Digital Immigrants

Another topic that I want to introduce is the idea of the digital natives versus digital immigrants. A digital native (i.e., a millennial) is a person born or brought up during the age of digital technology, and therefore familiar with computers and the internet from a very early age. A digital immigrant, on the other hand, was born or brought up before the widespread use of digital technology. 

I am a digital immigrant. I remember when my computer could connect to the internet for the first time. I used to have my email through America Online, and I remember hearing, "You've got mail." I was so excited to be able to communicate online with people all over the world. Now, I have graduate students who are digital natives. They have never been without the internet. The internet has always been a part of their lives. They have grown up with this ability to constantly connect and share information. They don't want to disrupt their entire schedule and spend their day going to a clinic or hospital to deal with a medical situation. They want to connect directly to their provider to obtain advice, or to have their doctor send a prescription to the local pharmacy. 

Digital natives are our future. Millennials will be having the children that will need our services as SLPs. The digital natives are embracing change, and the digital immigrants need to follow suit. In fact, 60% of millennials support the use of telehealth to replace in-office visits. With a population of 80 million, millennials now comprise the largest segment of today's workforce (Guttman, 2017). We have to wrap our heads around their expectations for how they want to interact with service providers.

Terminology 

Before going any further, we should clarify the nuances between the following terms: telehealth, telemedicine, and telepractice.

Telehealth. The Agency for Healthcare Research and Quality (AHRQ) states, “telehealth is the use of telecommunications technologies to deliver health-related services and information that support patient care, administrative activities, and health education.” According to the World Health Organization (WHO), telehealth includes “surveillance, health promotion, and public health functions.”  The services provided can be from a physician or some other medical personnel, such as a nurse. It could be actual diagnostic or treatment services, or it could just be information that's being shared. 

Telemedicine. As defined by the American Telemedicine Association (ATA), “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status." The ATA goes on to state that "closely associated with telemedicine is the term telehealth, which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth." 

Telepractice. Telepractice includes the use of telecommunications and web-based applications to provide assessment, diagnosis, intervention, consultation, supervision, education and information across distance. It is appropriate for many professions to engage in telepractice as a service delivery model, such as speech-language pathology, occupational therapy, and psychology/mental health professions. Specifically as it relates to SLP, ASHA defines telepractice as "the application of telecommunications technology to the delivery of speech-language pathology and audiology professional services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and/or consultation." ASHA adopted the term telepractice rather than the frequently used terms telemedicine or telehealth to avoid the misperception that these services are used only in healthcare settings. Telepractice is using telecommunications technology to interact with other providers, other professionals, or with your client or patient.

SLPs and Telepractice

Since the early 2000s, ASHA has considered telepractice as an appropriate model of service delivery for the professions of speech-language pathology and audiology. However, services delivered through telepractice have to be at the same level of quality as those services that you would deliver in person to that patient. In other words, if you cannot sufficiently provide the treatment that you want to provide to that patient through telepractice, it should be provided in person.

Within speech-language pathology, telepractice has been around since the early 1970s. It is only within the past several years when technology - combined with demand - has pushed telepractice service delivery models forward. We now have the technology to be able to deliver SLP services via telepractice in a consistent and reliable manner. Taking advantage of this new market, some companies have recently emerged that offer virtual SLP services (i.e., Presence Learning and Tiny Eye).

Janet Brown, who recently retired as ASHA's director of health care services in speech-language pathology, is quoted as saying:

Telepractice is not a different service, but rather a different method of service delivery (Janet Brown, 2010).

I view telepractice as another tool to put in your toolbox. We are providing traditional SLP services, but simply doing it via a different delivery model. We can still meet our clients' needs and carry out our treatment plan without physically being in the same room.