EDUCATION AND PRACTICE Overview

...................................................................................................................................................

" Audiology telemedicine

Mark Krumm
School of Speech Pathology and Audiology, Kent State University, Ohio, USA

Summary
Various real-time telemedicine applications have been investigated in audiology, including pure tone
audiometry, otoacoustic emission testing, auditory brainstem response recordings, hearing aid fitting and video-
otoscopy. Store-and-forward applications have usually been used to transmit basic patient data including case
history information and hearing screening results, although both video-nystagmography and video-otoscopy
have been piloted. Remote access to computerized equipment is relevant to audiology telemedicine, although
there have been few reports of the use of application sharing using computerized audiology equipment. In a pilot
trial of real-time telemedicine, both pure tone and speech audiometry measures were provided remotely through
application sharing. Audiology telemedicine appears promising, but it is at an early stage of development and
many areas such as its cost effectiveness, patient acceptance and test efficacy require systematic investigation.

Introduction methods. In the context of audiology, real-time

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Comprehensive hearing health-care programmes are
frequently complex and so there are often substantial
barriers to their realisation. For example, Mencher
et al.1 found that early intervention programmes for
hearing impaired children were commonly hindered
by inadequate funding, lack of planning, poor patient
tracking and insufficient professional expertise. Similar
obstacles have been noted by other researchers.2–6 In
response, O’Neal et al. called for new models to be
developed.7 These new models may employ
telemedicine.
Audiology telemedicine services have been trialled
in Australia, Brazil, Britain, Canada and the US.8 The
American Speech-Language-Hearing Association (ASHA)
has also developed a position statement supporting
audiology practice by telemedicine.9 However, the
ASHA has insisted that telemedicine services should be
equal in quality to those provided face to face.
applications which have been investigated include
pure tone audiometry, otoacoustic emission testing,
auditory brainstem response recordings, hearing aid
fitting and video-otoscopy.8,10
Store-and-forward applications have usually been
used to transmit basic patient data including case
history information and hearing screening results,
although both video-nystagmography (VNG) and
video-otoscopy have been piloted. One unusual
asynchronous application is self-assessment of hearing
acuity. Although controversial, self-assessment has the
potential to identify hearing-impaired patients in a cost
effective manner that requires little clinician
involvement.11
The best way to use telemedicine in audiology will
probably turn out to be a hybrid model incorporating
both synchronous and asynchronous techniques.
Synchronous methods would be used when greater
professional expertise was required for patient services
and asynchronous methods for less complicated
hearing health-care procedures.

Delivery modes
Telemedicine services can be delivered by real-time
(synchronous) or by store-and-forward (asynchronous)
Accepted 28 February 2007
Correspondence: Dr Mark Krumm, School of Speech Pathology and
Audiology, A104 Music and Speech Bldg, Kent OH 44242, USA
(Fax: þ1 330 672 2643; Email: mkrumm@kent.edu)
Equipment
For videoconferencing, a 384 kbit/s connection is
desirable as a lower bandwidth will result in a poor
quality interaction between the parties. When band-
width is limited, store and forward services can be
implemented instead.

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Computerized audiometry equipment permits
easy interfacing to telemedicine equipment. Most
manufacturers now produce Windows-compatible
audiometry equipment and it is similar in cost to
traditional analogue equipment. Computerized
audiometry systems that provide for a wide range of
test capabilities are particularly desirable for hearing
loss assessment and are suitable for audiology
telemedicine.
Application sharing allows two or more users to access
a shared application or document from their respective
computers simultaneously in real time. Remote access
to computerized equipment is relevant to audiology
telemedicine, although there have been few reports
of the use of application sharing using computerized
audiology equipment. The following sections describe a
pilot trial of real-time telemedicine in which both pure
tone and speech audiometry measures were provided
remotely through application sharing.
Real-time audiometry testing
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When any audiology telemedicine services are
provided (including remote computing applications) a
facilitator will be needed at the patient’s location. The
duties of the facilitator commonly include assisting the
clinician with video-otoscopy procedures, headphone
placement, observation of patient response patterns
and basic remote computing operations. Obviously the
facilitator will need training before any telemedicine
programme begins.
Using application sharing, clinicians at one location
can assume control of computerized audiometry
Patient Site
Web-cam & PC
Site Facilitator PC based audiometric
equipment
used for hearing tests
Patient
Figure 2 Configuration of the real-time audiology telemedicine system
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M Krumm Audiology telemedicine
systems at other locations to administer hearing
services. In our pilot trial we used a commonly
available audiometer (Avant audiometer, MedRx, Inc.,
Largo, FL) for pure tone testing. This was placed at the
patient’s location (Figure 1). As the audiometer was
a Windows based peripheral, it could be used for
application sharing without modification. Standard
commercial software was used for PC-based
videoconferencing (PVX, Polycom, Pleasanton, CA)
and a fixed lens webcam.
The videoconferencing software included an
application-sharing program. The configuration is
shown in Figure 2. There were two display screens: the
first, for videoconferencing, on which the patient
viewed the remote examiner; the second screen
displayed the audiometry results, as seen by the remote
Figure 1 The computerized audiometry equipment at the
patient’s site included the audiometer unit (positioned
under the laptop computer) and an auxiliary monitor. The
audiometer headphones and a client handheld switch are
located in front of the computer
Examiner Site
Web-cam &
Internet or PC
Network
Computer
communications
established by
remote
control/desktop
sharing software
Examiner
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Figure 3 The equipment at the patient’s site. The practitioner is displayed on the left-hand
screen. The facilitator can view the audiometry results on the right-hand screen

Figure 4 A partially completed audiogram obtained by application sharing. In this example,

the client raised her hand to indicate that she was hearing pure tone stimuli

examiner. The second screen was visible to the
facilitator, but not the patient (Figure 3).
Privacy
When services are provided by telemedicine,
administrators often insist on robust network security.
One well-known method of security is the virtual private
network (VPN). A VPN allows secure data transmission
over the Internet. Another method of security is data
encryption and is commonly available with commercial
videoconferencing equipment. The common standard of
128-bit encryption provides a high level of security. In
the present example, the encryption software included
in the videoconferencing system was used.
Test procedure
The clinician should ask the facilitator to adjust the
video equipment to view the client, to verify patient

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Figure 5 The audiometer located at the patient’s site was capable of playing recorded
speech for diagnostic purposes. In this example, a spondee word ‘PLAYGROUND’ was
presented to the patient through her headphones and simultaneously displayed on the
clinician’s screen. The clinician could monitor the patient’s verbal responses using the
videoconferencing system. Following the patient’s response, the clinician could change the
ear of stimulation, spondee word loudness levels and the type of word stimulus as needed

Figure 6 An auditory brainstem response (ABR) being obtained via real-time telemedicine.
The monitor shows the ABR controls as well as the patient’s ABR tracings. The patient can be
observed (right) through a webcam, together with the audiologist who is conducting the test
from a remote site (upper right hand window)

headphone placement and to ensure that the patient
responses are clearly recognizable. The clinician should
confirm the patient’s response to a test stimulus, e.g. by
asking the patient to raise a hand.
After assuming audiometer control via the remote
sharing application, the audiologist can change
hearing testing variables (such as test frequencies and
presentation levels), modify the tempo of testing to
accommodate patient needs and re-test stimuli as
required. In other words, the audiologist controls the
audiometer at the patient site using the application
sharing software much as services are provided in a

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M Krumm Audiology telemedicine

face-to-face setting. Figure 4 shows the progress in
pure tone testing conducted on the patient during a
telemedicine session.
The audiometer could produce the pure tone and
speech stimuli used for typical hearing evaluations.
Speech testing options were available by selecting the
‘SRT’ option for spondee testing or the ‘DS’ option for
phonetically balanced words. These speech tests form
the basis of a traditional comprehensive examination.
Tests could be selected at the upper left hand corner of
audiometer main menu (Figure 5). Note that in Figure 5
the spondee word displayed on the audiologist’s
computer screen was presented to the patient via the
headphones. In addition, the practitioner could choose

Figure 7 Hearing aid software can be programmed using application sharing. This may
prove to be a useful method of adjusting these devices in distant communities

Figure 8 Distortion product otoacoustic emissions (DPOAE) testing being conducted by

telemedicine on a paediatric client. The clinician can control intensity levels, test frequencies
and algorithms to enhance DPOAE responses. Application sharing also permits other
diagnostic protocols, such as transient otoacoustic emissions (TEOAEs) and spontaneous
otoacoustic emissions (SOAEs)

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which words were presented, control the volume of the
word stimuli and could select which ear will be tested.
Other audiometric equipment that can be used with
application sharing software includes the auditory
brainstem response, hearing aid programming and
otoacoustic emissions. Examples of these procedures
are shown in Figures 6–8.
Counselling
Results and recommendations derived from audiology
services provided by telemedicine will require
counselling and it would be natural to perform the
counselling using telemedicine. Unfortunately, little is
known about counselling by telemedicine in the case
of hearing loss. This is an important matter because
considerable effort may have been expended by the
audiology service, and this could be jeopardised if a
grieving patient (or parent) experiences denial over the
discovery of hearing loss.
Records
Before disconnecting from a telemedicine session, the
clinician should save any relevant client records.
Ideally, such data would form part of an electronic
patient record that could be accessed by patients
and by their health-care providers. However, when
customized software is unavailable, most application
sharing software will permit file transfer to the
clinician’s computer.
Conclusion
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The audiometer used in our pilot session was selected
because it was computerized and compatible with
application sharing software. Similar equipment is
available from other manufacturers. In addition,
hearing health professionals often possess other
computerized audiometry systems that may be suitable
for telemedicine applications. Such equipment
includes audiometers, otoacoustic emissions systems,
auditory brainstem evoked response systems and
hearing aid programming devices.
There is a wide range of videoconferencing
equipment. Although dedicated video systems
may be preferable, webcams and inexpensive
videoconferencing software can be used to provide
surprisingly effective real-time telemedicine. For
example, a hearing test was conducted by an
audiologist at the Federal University in Sao Paulo,
Brazil with the subject located at Kent State University
in the US. The pure tone and speech audiometry tests
were successfully administered using application
sharing techniques. The software used for this purpose
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M Krumm Audiology telemedicine
was Netmeeting, which is free videoconferencing
software included with the Windows operating system.
Clearly, audiology telemedicine is at an early stage
of development and many areas such as its cost
effectiveness, patient acceptance and test efficacy
require systematic investigation. So far, almost all
audiology telemedicine trials have delivered only
a single service (e.g. pure tone audiometry or
tympanometry). In order to mimic face to face
audiometry, hearing health professionals will need
to have the capacity to deliver a battery of tests for
diagnostic testing and hearing screening.
The findings from preliminary telemedicine research
projects generally support the use of telemedicine for
hearing health-care services. The benefits of audiology
telemedicine include greater continuity of services,
increased professional expertise and a more accessible
‘family friendly’ hearing health programme. However,
investigations focusing on comprehensive field based
services require further validation.
Acknowledgements: I am grateful to Dr Richard Klich
for his invaluable review and editorial comments
concerning this manuscript.
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