The cost consideration of the implementation of tele-audiology services

The cost consideration of the implementation of tele-audiology services in one’s practice stretches far beyond the cost of the equipment used. Other costs and resources include training of a facilitator, facilitator remuneration, internet connectivity and communication tools between the clinician and the facilitator. These are important to consider when implementing tele-audiology services. This paper outlines the nitty-gritty of resources involved with tele-audiology in one’s clinical practice. 

It is important to note that the costs associated with tele-audiology resources (i.e. internet connection, facilitator costs) may vary from region to region – and costs includes both financial and non-financial resources.Thus it is important to use this article as a guide for your own research regarding the costs related to the details outlined here. Note that the financial values in this paper will be expressed in United States Dollars (USD). 

Facilitator training

Tele-audiology clinicians should take into consideration the facilitators’ educational training, skills and experience, and the amount of training that they require in order to be effective and efficient as tele-audiology facilitators. Two of the major training requirements for facilitators are; 1) computer skills, and 2) hands-on-related aspects of patient site testing.

1)  Computer skills. Tele-audiology, either synchronous or asynchronous, relies heavily on computer technology. Patient-site facilitators are tasked with controlling the computer at the patient site in order to connect with the offsite audiologist, or start an automated audiometric test and forward the test results to the audiologist offsite. As a result, it is crucial for the patient-site facilitators to be proficient in computer skills. This skill, if lacking, may be provided through training by the tele-audiology coordinator, an IT personnel, or by enrolling the patient-site facilitator into a day or two of basic computer training. 

    • The training of facilitators on computer skills may be done through online courses  such as Udemy (~$40) or for free on YouTube. It is important to go through the content of the training to ensure that it covers the skills required for the patient-site facilitator role. 

2) Hands-on-related patient-site testing. The patient-site facilitator is a hands-on extension of the clinician (usually an audiologist) who is providing tele-audiology services. They play a paramount role in the service delivery of audiology services through tele-communication platforms. As a result, it is crucial to spend sufficient resources and time in training patient-site facilitators on their expected role. 

    • A study by Coco et al. (2020) found that the top five duties conducted by patient-site facilitators were: 1) Conduct/ assist with (video) otoscopy, 2) perform or assist with hearing assessments, 3) placement of transducers on patients, 4) instructions to patients on test procedures, and 5) conduct or assistance with immittance audiometry testing. 
    • On the other hand, the same study found that the educational background of patient-site facilitators varied from: 1) audiologist, 2) student, 3) technician (with unknown background), 4) physician, and 5) Community Health Worker. 

As noted above, the varied educational backgrounds and the duties conducted by patient-site facilitators, indicates the need for additional training in order for facilitators to execute their roles appropriately. Besides audiologists, patient-site facilitators do not have the skills nor the knowledge to perform most of the patient-site duties without training. Something as routinely simple as inserting an earphone eartip for audiometry testing needs training and practicals until the facilitator is confident to insert eartips. The insertion of a foam eartip or placement of bone vibrator on the mastoid or forehead can prove to be difficult without the appropriate background education. This is why I recommend the use of forehead bone conduction because of the low risk of incorrect placement, the fact that you can easily verify the placement through a video link and because it is easy to perform the action. It is also important to select the best equipment for the job and for the facilitator to get appropriate training depending on the equipment that will be used.

Training of facilitators should include general training of skills but also specific training on roles and responsibilities that are expected of them. For example, if the facilitator will be responsible for conducting video otoscopy and sharing the files with the audiologist, then the facilitator should be trained in otoscope specula size selection, infection control and maneuvering the otoscope appropriately and effectively to yield the design outer ear/ tympanic membrane imaging. 

Facilitator remuneration

The remuneration expectation for a patient-site facilitator will vary depending on a lot of factors. These include, 

1) their background education, 
2) skills and experience, 
3) region of employment, and 
4) what is required of them as facilitators – to name just a few. 

Many countries do not regulate or have guidelines of required patient-site facilitator educational background and specifically what their training should be in order to allow for them to assist in the provision of tele-audiology services. As a result, it is the responsibility of the audiologists or tele-audiology coordinators to outline the duration of training and training required for their specific patient-site facilitator. It is also the responsibility of the audiologist to validate that the training is adequate.

There is a lack of jobs around the globe and the United States is not exempted from this. As a result, many graduates are without jobs. A quick search of average intern salaries in the USA yielded ~$14.29 per hour on indeed.com. Graduates today have higher computer skills compared to those of the past (obviously computers were not a thing back then), thus, an intern of almost any educational background could be trained and employed as a patient-site facilitator for tele-audiology services. 

Internet connection fees

Internet package plans will vary from one tele-audiology program to another. If a pay for data used data bundle is used then it is important to take into consideration the data usage costs. If implementing synchronous tele-audiology (i.e. live consultation/testing/management with audiologist through desktop sharing softwares and/ or video communication tools) then the internet package purchased might need to be slightly higher than asynchronous tele-audiology (store and forward).

  • It is important to pilot how much data remote desktop software, such as TeamViewer, may use during tele-audiology services so that you may purchase enough data (*if using pay for data used data bundle). 
    • TeamViewer, or similar apps, may be used to allow the offsite audiologist to control the patient-site test equipment such as the audiometer. 
  • According to xplornet, Skype uses roughly 270 MBs per hour on a video call. 
    • Skype or similar (i.e. WhatsApp video call) may be used to allow for an offsite audiologist to observe and communicate with patients and facilitators during testing.

For asynchronous tele-audiology, one needs to consider data used when transferring the automated test results from patient-site (by the facilitator) to the audiologist. Depending on the size of the files sent, the data used will vary. Most files sent (i.e. video otoscopy files) may not be bigger than 5 MBs – so the use of store and forward tele-audiology may require very little data in general.

Clinicians should attempt to have an idea of how many sessions they might have and require data usage in order to calculate how much data might be needed on the patient-site and audiologist-site per month.

Equipment price

There are two considerations one should make when purchasing tele-audiology equipment. 1) What the equipment offers (i.e. boothless, comprehensive testing, portability etc), and 2) the actual price. eMoyo has covered both these topics in previous articles. The general prices of boothless audiometers can be found here . It is important to note the tests that each device can provide. There are also key considerations when using a tele-audiology equipment for your services such as its ability to be used outside of a booth, to provide comprehensive diagnostic testing with one device, and automation, in the case of asynchronous tele-audiology implementation. 

The implementation of tele-audiology services in one’s practice needs a lot of thought and consideration. From a clinical standpoint to a financial and logistical point of view.