Clinical Focus ■ Innovation
Internet Application to Tele-Audiology—
“Nothin’ but Net”
Gregg D. Givens
Saravanan Elangovan
East Carolina University, Greenville, NC
The Telehealth program at East Carolina
University has developed a system for real-time
assessment of auditory thresholds using
computer driven control of a remote audiometer
via the Internet. The present study used 45
adult participants in a double-blind study of 2
different systems: a conventional audiometer
and an audiometer operated remotely via the
Internet. The audiometric thresholds assessed
by these 2 systems varied by no more than 1.3
dB for air conduction and 1.2 dB for bone
T
elehealth is the use of information and communica-
tion technology to transfer information and/or data
in the support of health care. Telehealth is an
umbrella term that encompasses any medically related
activity involving an element of distance. The area is in
relatively early stages of development but is beyond the
conceptual and start-up phase (American Speech-
Language-Hearing Association [ASHA], 2001). Telehealth
has existed in some form or another for more than 40 years
(Ashley, 2002). However, much of its progress was
hindered in early years by costs and limitations in technol-
ogy. Rapidly decreasing costs of technology (Whitten &
Collins, 1997), technological advances such as the World
Wide Web (Bergeron, 1998), and increased federal, state,
and military support (Edwards & Mota, 1997) led to a
rebirth in the late 1990s. The first reference in medical
literature for telemedicine described the 1948 transmission
of radiological images by telephone (Field, 1996).
It has only been in the last few years that investigations
in telehealth have moved from working with prototypes
that test clinical possibilities to evaluating new systems as
to their utility and validity in the clinical setting. The
impact of telehealth in health care could be tremendous
(McCarty & Clancy, 2002), including the possibility of
providing quality health care through telecommunications
technology to underserved populations in prisons, inner
cities, and rural locations, and to elderly people in long-
term care facilities (Bashshur, 1997) in the United States
and abroad (Bashshur, 2002; Larkin, 1997; Plock, 1998).
American Journal of Audiology • Vol. 12 • 59–65 • December 2003 • © American Speech-Language-Hearing Association
1059-0889/03/1202-0059
conduction. The results demonstrated the
feasibility of this new “telehearing” audiometric
system. With the rapid development of Internet-
based applications, telehealth has the potential
to provide important healthcare coverage for
rural areas where specialized audiological
services are lacking.
Key Words: telehealth, telemedicine, Internet,
audiology
Telehealth practitioners now have the potential to make a
global impact on health care delivery in their respective
professions. “Telediagnosis” (McCarty & Clancy, 2002)
has been demonstrated to be a viable and reliable alterna-
tive, despite the difficulties caused by the lack of kinetic
and facial cues. A study at the Medical Center of Central
Massachusetts compared face-to-face and teleconferenced
psychiatric diagnosis for ratings on multiple psychiatric
scales among patients who were involuntarily admitted.
When the individual ratings of the “in room” psychiatrist
were compared with those of the telepsychiatrist, the
results for 12 individual evaluations revealed a mean
weighted Kappa coefficient of 0.85, F(95, 95) = 20.85,
p < .001. Therefore, the telediagnosis had an excellent
correlation with the face-to-face psychiatric diagnosis
(Bear, Jacobson, Aaronson, & Hanson, 1997). A similar
investigation was conducted in the field of communication
sciences and disorders. Duffy, Werven, and Aronson
(1997) evaluated speech-language pathology consultations
conducted by the Mayo clinic in conjunction with the
National Aeronautics and Space Administration’s (NASA)
Advanced Communications Technology Satellite (ACTS).
Live videoconferencing consultation of 8 patients and a
retrospective evaluation of 24 video-recorded samples of
speech disorders were assessed both by an “in room”
clinician and by a clinician at a remote site. The results
indicated that the satellite videoconference consultations
and diagnosis were comparable to face-to-face consulta-
tions and diagnosis. Further, the study reported that the
Givens & Elangovan: Internet Application to Tele-Audiology 59
patients were satisfied with the satellite consultations and
felt that the consultation adequately reflected their commu-
nication abilities.
ASHA recognized the huge potential of telehealth
practices and directed a team to investigate its current
status and probe for future directions in the field of
communication sciences and disorders (ASHA, 2001). This
team adopted the term telepractices to encompass both the
delivery of clinical services and the provision of health
related information. Telepractices was broadly defined “as
the application of technology to deliver health services at a
distance by linking clinician and patient or clinician and
clinician to provide any or all of the following: (1) training,
counseling, education; (2) assessment—establishing
patient status; (3) intervention—treatment/management,
and to provide remote support and training of practitio-
ners” (ASHA, 2001, p. 3). The Telepractices Team’s report
emphasized the need for ASHA and its members “to
improve their use of Web-based and advanced technology
to enhance the provision of personnel preparation, provi-
sion of clinical services including telepractices, and
program administration” (ASHA, 2001, p. 1).
Several applications of telehealth in the field of commu-
nication sciences and disorders have been described in
ASHA publications, in the Journal of Telemedicine and
Telecare (Hill & Theodoros, 2002), and in the recent report
of the ASHA Telepractices Team. An early study by
Vaughn (1976) described the effectiveness of a telehealth
program that sought to improve the availability and accessi-
bility of speech and language services in a cost-effective
manner. This program developed “Tel-communicology,” a
method of service delivery using the telephone in conjunc-
tion with education materials previously mailed to the
patient. This service delivery model, which included a full
range of services, such as patient–clinician sessions;
consultations between patient, clinician and consultant; and
educational lectures for staff, was implemented as a
supplement to traditional services, principally for follow-
up. The results of this investigation indicated a significant
reduction in costs and travel time, and an increase in the
number of patient–clinician contacts (Vaughn, 1976). More
recently, Telehealth was reported to have been initiated in
applications such as voice therapy (Mashima, Birkmire-
Peters, Holtel, & Syms, 1999), assessment of dysphagia
(Lalor, Brown, & Cranfield, 2000), articulation therapy
(Scheiderman-Miller & Clark, 2000), stuttering therapy
(Kully, 2000), and diagnostic audiometry (Krumm, Ribera,
& Froelich, 2002), and in the rehabilitation of acquired
brain injury (Ricker et al., 2002).
Audiologists have been using some kind of telehealth
practices on a regular basis in a limited manner for diagnos-
tics, hearing aid fittings, and counseling (Krumm, Ribera, &
Froelich, 2002). Any kind of remote communication with
patients constitutes some element of telehealth. One of the
main challenges faced by the health care systems is to
provide for consumers living in isolated or rural communi-
ties. These populations will probably benefit the most from
telepractices. In these circumstances, telehealth acts as a
technology medium that brings the consumer “face-to-face”
with the clinician even when they are hundreds of miles
60 American Journal of Audiology • Vol. 12 • 59–65 • December 2003
apart. Toward this goal, telehealth takes different forms.
One of the forms that allows for synchronous “real time”
diagnosis involves remote control computing that enables
clinicians to test individuals at distant locations. Remote
control software applications permit the clinician to control
computers and their peripherals, as pure-tone audiometry
and otoacoustic emissions located at the consumer sites.
Such a venture has already been attempted and results have
been reported to be promising (Krumm, Ribera, &
Froelich, 2002).
The telehealth program at East Carolina University took
this evolving telehealth technology and developed a system
for the application of real-time diagnostic audiometry via
the Internet. The system is organized as a real-time
assessment of auditory thresholds using computer driven
control of a remote audiometer via the Internet. The
following is a description of a recently completed study
using the “tele-audiometry” system.
Method
Tele-Audiometry System Description
ECU Telemedicine Center engineers devised a means of
communicating with a commercially available audiometer
via an Internet protocol (IP) network, allowing an audiolo-
gist to remotely conduct a hearing test using a desktop or
palmtop computer and an Internet connection. The tele-
audiometry system (see Figure 1) comprised three primary
subsystems: (a) a controller that interfaced at a low level
with the audiometer, (b) a micro Web server that managed
the IP connection and acted as a “traffic cop” between the
microcontroller and the remote user/consultant (i.e., the
audiologist), and (c) a remote computer, either a desktop
PC or palmtop personal digital assistant (PDA) that used a
specially developed Microsoft Windows or Palm OS client
program.
The audiometer, Maico Diagnostics’ MA40 (Eden
Prarie, MN), was inherently capable of communicating its
current status through a built in serial port. However, it
could not be controlled through this serial port. Therefore,
a controller was developed using Microchip Technology’s
PIC16C74B 8-bit microcontroller and a MAX232A
RS232/TTL conversion chip to control the audiometer’s 10
digital switches and dual encoders. The controller used 10
digital pins for the audiometer’s 10 controls, 8 digital pins
to manage the rotary encoders, and a serial port (transmit/
receive pins). The following were controlled: (a) ear
routing, (b) air/bone conduction, (c) transducer (insert or
head phone), (d) stimulus interrupter, (e) stimulus lock, (f)
frequency modulation, (g) pulsed stimulus, and (h)
masking. The two encoders controlled the attenuation of
the primary stimulus and masker. The controller’s func-
tions were transparent to the user, meaning that the
audiometer could be controlled from the audiometer’s user
interface, from the controller, or from both simultaneously.
A micro Web server (Rabbit Semiconductor’s RCM-
2200) was used to enable remote communications with the
controller and the audiometer. The RCM-2200 acted like a
bridge between Internet commands and the controller. The
Web server’s functionality enabled it to send and receive
FIGURE 1. A block diagram of the tele-audiometry system.

information to the controller and the audiometer simulta- FIGURE 2. The Palm OS client software allows the audiologist
neously, while hosting a Web server for connection with to remotely control the audiometer via an Internet protocol
connection.
the client PC or PDA. The micro Web server commanded
the controller, while verifying that a change was made
using the output from the audiometer. This provided
redundant verification that the audiometer was using the
correct intensity and frequency settings, as well as which
ear was receiving audio tones. This was essential to verify
that the participant was actually receiving the correct tones.
The micro Web server was programmed to constantly
look for an IP socket connection from a remote host (PC or
PDA). As described previously, both Microsoft Windows
and Palm OS clients (see Figure 2) were developed to
connect to the rabbit, control the audiometer, and receive
feedback. This allowed an audiologist to control the
audiometer from any location within an IP connection.
Therefore, the system could be operated over the Internet,
within an isolated local or wide area network within a
health system, or via a dial-up connection. Also, the use of
the low cost components in the controller and micro Web
server subsystems obviated the need for a PC to be directly
connected to the audiometer. This kept the cost of upgrad-
ing an audiometer to a bare minimum. In addition, al-
though this solution was used with a specific audiometer,
the system was designed so it could be applied to any
audiometer.

Procedure
Forty-five adult participants (M = 24 years, range =
20–53 years) were used in the air conduction condition.
Twenty-five (M = 23 years, range = 19–45 years) of the
original 45 adult participants were used in the bone
conduction condition. The number of participants varied
between the two transducer conditions because the

Givens & Elangovan: Internet Application to Tele-Audiology 61

 TABLE 1. Mean, standard deviation, and range for air conduction thresholds (dB HL) measured
under both audiometric systems.

Frequency (Hz)
Measure
(dB HL) 250 500 1000 2000 4000 8000

Standard
M 12.4 11.7 9.2 8.8 10.6 14.6
SD 6.1 8.1 7.7 7.4 11.8 10.9
Range 5–30 0–40 0–35 0–40 0–60 0–50
Telehearing
M 13.2 11.6 9.3 8.6 11.1 14.9
SD 5.9 8.3 8.6 7.3 11.4 10.3
Range 5–25 5–35 0–30 0–35 0–35 5–55
Mean difference 1.3 0.4 0.3 0.0 0.8 0.8

technology for bone conduction testing was developed at a
later time during the study. Participants were tested in a
double blind study of two different systems for assessing
auditory pure-tone thresholds. One system consisted of a
standard audiometer, and the second system consisted of
the same audiometer operated remotely via the Internet.
The participants were selected at random from college
students and faculty in the School of Allied Health
Sciences at East Carolina University. Each participant
received an auditory threshold assessment with two
different audiometric systems. The participants had no
knowledge of which audiometric system was being used in
the assessment procedure. The conventional and tele-
audiometer were operated by two independent audiologists
for every individual participant. The audiologists were
blind to the results of previous testing for any particular
individual. The threshold procedure administered followed
the ASHA guidelines for audiometric evaluation (ASHA,
1985). The test ear as well as the order of test procedure
was counterbalanced. Air conduction thresholds were
assessed at octave intervals between 250 and 8000 Hz, and
bone conduction thresholds were assessed at octave
intervals between 250 and 4000 Hz.
All tests were conducted in a sound treated room
meeting the ANSI S3.1-1991 standards. (American
National Standards Institute [ANSI], 1991) The audiom-
eter was calibrated to ANSI S3.6-1996 standards (ANSI,
1996). The audiometer employed was a Maico Model
MA 40 with TDH-49 earphones and a Radio Ear B 71
bone oscillator.
Results
The mean, range, and standard deviation of the auditory
thresholds for air conduction for each system as a function
of frequency are presented in Table 1. The mean, range,
and standard deviation of the auditory thresholds for bone
conduction for each system as a function of frequency are
presented in Table 2. The relationship between the thresh-
olds estimated by the two systems as a function of fre-
quency can be seen in the scatter plot matrices in Figures 3
and 4, for air conduction and bone conduction, respec-
tively. Also shown in the scatter plots are a least-squares
regression line along with the regression equation and
coefficient of determination (r2) for each individual test
frequency. As can be seen in Figures 3 and 4, both the
regression coefficient (β in the regression equation) and the
coefficient of determination (r2) are close to unity, for
both the air and bone conduction thresholds, suggesting
that the relationship between the auditory thresholds
estimated by the two audiometric systems is linear and very
highly related. Pearson’s product–moment correlation
coefficients were high and significant (α = .01) between
thresholds estimated through the two systems for all the test

TABLE 2. Mean, standard deviation, and range for bone conduction thresholds (dB HL) measured
under both audiometric systems.

Frequency (Hz)
Measure
(dB HL) 250 500 1000 2000 4000

Standard
M 8.8 7.6 5.0 5.2 6.8
SD 7.2 9.0 10.7 4.9 12.2
Range 0–30 0–40 0–40 0–15 0–60
Telehearing
M 9.6 7.8 5.4 5.2 5.8
SD 7.0 9.1 9.6 6.2 12.1
Range 0–30 0–40 0–35 0–20 0–60
Mean difference 0.8 0.2 0.4 0.0 1.0

62 American Journal of Audiology • Vol. 12 • 59–65 • December 2003

FIGURE 3. Scatter plots showing the relationship between the air conduction thresholds estimated by the conventional and
telehearing system for the test frequencies (a) 250 Hz, (b) 500 Hz, (c) 1000 Hz, (d) 2000 Hz, (e) 4000 Hz, and (f) 8000 Hz. Shown also
in the individual scatter plots is the least-squares regression line along with the regression equation and coefficient of determina-
tion (r 2). The reason for the varying number of symbols (each symbol represents a pair of thresholds estimated by the audiometric
systems for an individual participant) in the scatter plots of different test frequencies is the overlap of auditory thresholds between
the participants.

frequencies, for both air conduction (M = .86, range = .82–
.92) and bone conduction (M = .94, range = .90–.97).
A two factor repeated-measures ANOVA was also used
to examine mean differences in auditory thresholds as a
function of system and frequency. A nonsignificant main
effect of system was found for air, F(1, 44) = 0.387,
Greenhouse–Geisser p = .537, η2 = .009, φ = .093 (at α =
.05), and bone conduction thresholds, F(1, 24) = 0.066,
Greenhouse–Geisser p = .799, η2 = .003, φ = .057 (at α =
.05). In other words, both systems provide the same
audiometric results. Mean thresholds using the two systems
varied by no more than 1.3 dB for air conduction and 1.2
dB for bone conduction, well within established variability
of audiometric testing (Harris, 1978).
A significant main effect for frequency was evidenced
for the air conduction thresholds, F(5, 220) = 5.292,
Greenhouse–Geisser p = .003, η2 = .107, φ = .898 (at α =
.05), but not seen for the bone conduction thresholds, F(4,
96) = 1.258, Greenhouse–Geisser p = .292. This statistical
difference could probably be because of the difference in
sample size (smaller sample size for the bone conduction
experiment). More relevant to our purpose was to examine
whether there was any significant difference between the
thresholds evaluated with the two different systems as a
function of the test frequency. No statistically significant
interaction was observed between the factors, system and
test frequency, for both air, F(5, 220) = 0.562, Green-
house–Geisser p = .690, and bone conduction, F(4, 96) =
1.418, Greenhouse–Geisser p = .240.
Discussion
The present study demonstrates the feasibility of a new
Internet-based audiometric system. With the rapid develop-
ment of the Internet and of Internet-based applications,
telehealth can potentially provide important health care
coverage for remote and rural areas where specialized
audiological services are lacking. However, before tele-
audiological services become a reality, additional analysis
is needed. Our current system is in the process of being
inserted into a rural medical clinic where data will be
examined relative to validity and reliability of measure-
ment, clinical efficiency, patient satisfaction, and clinical
outcomes.
If telehealth is to become a health care reality, several
issues have to be resolved, including (a) reimbursement,
(b) licensure, (c) expanded coverage area by Medicare and
private health plans, (d) adequate infrastructure in rural
areas, and (e) the cost of the technology. The ASHA
Telepractices Team has suggested measures to address

Givens & Elangovan: Internet Application to Tele-Audiology 63

FIGURE 4. Scatter plots showing the relationship between the bone conduction thresholds estimated by the conventional and
telehearing system for the test frequencies (a) 250 Hz, (b) 500 Hz, (c) 1000 Hz, (d) 2000 Hz, and (e) 4000 Hz. Shown also in the
individual scatter plots is the least-squares regression line along with the regression equation and coefficient of determination (r 2).
The reason for the varying number of symbols (each symbol represents a pair of thresholds estimated by the audiometric systems
for an individual participant) in the scatter plots of different test frequencies is the overlap of auditory thresholds between the
participants.

issues such as practice and outcome; ethical, liability, and
legal issues; reimbursement and issues related to medical
insurance coverage; licensure, accrediation, and certifica-
tion of service providers; preservice academic preparation
and continuing education of telepractice service delivery;
consumer education; and research issues (ASHA, 2001).
Ultimately, consumers will decide the fate of telehealth;
their demand for access to medical expertise through
technology will force health insurance carriers, state
lawmakers, and congress to tear down any legal and
regulatory barriers (Krizner, 2002). This relatively new
endeavor does not change the scope of practice of any
licensed healthcare professional. However, it does change
the scope of healthcare delivery.
Conclusions
We have demonstrated that real-time, Internet-based
assessment of hearing can be accomplished. This system
allows for remote assessment of hearing, providing
audiological care without an audiologist on site. Future
investigations will probe into issues concerning the
application of this technology to various clinical settings,
quantifying outcome, and cost analysis of the clinical
procedures.
Telehealth is quickly becoming less an “alternative
method of service delivery” and more about the wise
application of current and emerging technology to deliver
clinical services in a manner that has the potential to (a)
reduce barriers to access and specialized expertise, (b) be
cost-effective, and (c) enhance provider productivity and
consumer convenience (e.g., reduce the burden associated
with travel time or costs; ASHA, 2001). The area of tele-
audiology is certainly in its infancy but it shows tremen-
dous scope in various facets of the field of aural habilita-
tion/rehabilitation. Applications such as intraoperative
monitoring, fitting and programming of digital hearing
aids, activation and mapping of cochlear implants, audio-
logical diagnostic testing with otoacoustic emissions and
middle ear impedance measures, auditory training, and so
on, are but a few examples of potential areas where
teleaudiology can be implemented. If we believe there is
potential in this area, we have a moral as well as a profes-
sional responsibility to study and develop telehealth for
improved worldwide health care (Wooten, 2001).
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Received July 21, 2003
Accepted September 8, 2003
DOI: 10.1044/1059-0889(2003/011)
Contact author: Gregg D. Givens, PhD, Department of Communi-
cation Sciences and Disorders, School of Allied Health
Sciences, East Carolina University, Greenville, NC 27858.
E-mail: givensg@mail.ecu.edu
Givens & Elangovan: Internet Application to Tele-Audiology 65