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Perspect ASHA Spec Interest Groups. Author manuscript; available in PMC 2019
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September 20.
Published in final edited form as:
Perspect ASHA Spec Interest Groups. 2019 February ; 4(1): 100–110. doi:10.1044/2018_PERS-
SIG3-2018-0014.
Building a Successful Voice Telepractice Program
Elizabeth U. Grilloa
aDepartment of Communication Sciences and Disorders, West Chester University, PA

Abstract
Purpose: Telepractice offers prevention, assessment, treatment, and consultation at a distance.
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This article provides an overview of telepractice with specific considerations and examples related
to voice across licensure requirements, state and federal laws, reimbursement, documentation, and
telepractice methods.

Conclusion: As technology continues to advance and as client demand for telepractice services
increases, practitioners need to create successful telepractice programs.

The American Speech-Language-Hearing Association (ASHA) adopted the term 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, 2018a).
Other terms recognized by ASHA include teleaudiology, telespeech, and speech teletherapy
(ASHA, 2018a). Various disciplines and organizations recognize the broader terms of
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telemedicine and telehealth. The American Telemedicine Association recognizes the

specialized term of telerehabilitation to include both habilitation and rehabilitation services.
Telepractice, teleaudiology, telespeech, and speech teletherapy fall under the umbrella term
of telerehabilitation. The American Telemedicine Association defined principles for
delivering telerehabilitation services as a guide for practitioners, professional associations,
and other organizations in 2010 with an update in 2017 (Brennan et al., 2010; Richmond et
al., 2017). Practitioners need to be aware of the various terms to navigate the literature for
evidence-based sources and to communicate effectively across disciplines.

Rather than using medical terms (e.g., telemedicine and telehealth), telepractice implies that
services may be conducted anywhere, in schools, hospitals, universities, clients’ homes,
courtrooms, television studios, performance stages, teachers’ classrooms, and so forth. The
venues are limitless as long as the services comply with national, state, institutional, and
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professional regulations. Methods of telepractice include synchronous, asynchronous, and

hybrid approaches. Synchronous methods involve in real-time interactions using audio and
video connections through web-based videoconferencing between client and clinician, or
groups of clients and clinician, or consultation between a clinician, specialist, and client.
Asynchronous methods involve the storage of information that is accessed by the client
and/or the clinician apart from any in real-time interaction. Such information may include

Correspondence to Elizabeth U. Grillo: egrillo@wcupa.edu.

Disclosures
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client voice recordings, audio or video examples of voice treatment targets, daily practice
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schedules, vocal hygiene diaries, tele or evoice evaluation of acoustic, aerodynamic and
perceptual measures (Grillo, 2017a), and telebiofeedback of voice performance through
remote monitoring (Van Stan, Mehta, Petit, et al., 2017; Van Stan, Mehta, Sternad, Petit, &
Hillman, 2017). Hybrid methods may include a combination of synchronous and
asynchronous approaches. In addition, hybrid methods may also include a combination of
telepractice and in-person services.

The need for telepractice will continue to grow due to four fundamental benefits: (a)
improved access, (b) cost efficiencies, (c) quality of services, and (d) client demand.
Improved access through telepractice addresses issues with recruitment and retention of
speech-language pathologists (SLPs) in rural and remote areas and SLPs with appropriate
expertise to service multicultural and bilingual populations (Cason & Cohn, 2014; Pickering
et al., 1998). In addition, specialists may not be readily available in remote areas.
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Telepractice allows for consultations between specialists and the clinician working directly
with the client, therefore improving client outcomes. Telepractice is cost-efficient by
reducing travel costs for both the client and the clinician, hospital stay for medical
conditions (e.g., aspiration pneumonia, head and neck cancer, paradoxical vocal cord dys-
function), medical tests, and overall medical costs to the health care system (Burns,
Kularatna, et al., 2017; Burns, Ward, et al., 2017; Coyle, 2012; Towey, 2012a). Although the
benefits of telepractice are obvious in terms of improving access and reducing costs, another
benefit of telepractice is the quality of services. Telepractice is offered in the client’s
functional environment where they communicate on a daily basis, which is considered best
practices in many areas of rehabilitation (McCue, Fairman, & Pramuka, 2010) and is
supported by the World Health Organization intervention framework (World Health
Organization, 2001). The literature suggests that quality of service through telepractice
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produces similar clinical outcomes when compared with in-person services across
neurogenic communication disorders, fluency disorders, voice disorders, dysphagia, and
childhood speech and language disorders (Hill & Theodoros, 2002; Lowe, O’Brian, &
Onslow, 2013; Mashima & Brown, 2011; Mashima & Doarn, 2008; Swanepoel & Hall,
2011; Theodoros, 2008; Wales, Skinner, & Hayman, 2017). In some cases, the telepractice
method was superior to the in-person method by increased service efficiency, treatment
satisfaction (Burns, Ward, et al., 2017), and improved treatment outcomes for children
(Towey, 2012b). Clients, caregivers, and other professionals involved want and demand
access to telepractice. Using telepractice provides an ease of access through technology.
Such services offer clients access to practitioners who might not be available otherwise.
Considering voice, clients are no longer restricted to local voice therapists. Clients will seek
the most efficient and effective voice treatment available from across the region, state,
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country, or world. Millennials and digital natives will demand and expect nothing less than
convenient access to services through technology.

A significant body of literature exists for telepractice across communication and swallowing
disorders. The literature related to voice is more robust for voice treatment with less
evidence for assessment and prevention. Methods that will enable remote monitoring of
voice through repeated voice evaluations on a daily basis are needed. Recent work related to
assessment and telemonitoring of voice has focused on ambulatory voice measures captured

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through accelerometer sensors placed on the neck (Llico et al., 2015; Mehta, Van Stan, &
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Hillman, 2016). The sensors communicate with a smartphone application (app) to provide
information on voice use through acoustic and aerodynamic measures that can be used in
real time with clients. Other work has demonstrated that a tele or evoice evaluation
smartphone and tablet app (i.e., VoiceEvalU8) was successful in demonstrating voice change
from pre– to post–voice therapy in two global voice prevention model (GVPM) treatment
groups (i.e., in-person and telepractice; Grillo, 2017a). VoiceEvalU8 uses the microphone
within smartphones and tablets to capture audio recordings of the user for analysis of
acoustic measures and the aerodynamic measures of s/z ratio and maximum phonation time.
Perceptual measures are also available in VoiceEvalU8 through survey questions that the
user completes by touching the appropriate response.

Recent work related to voice disorders prevention and telepractice is investigating the effects
of the GVPM on the voices’ of student teachers during a 15-week semester of student
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teaching (Grillo, 2017a). There are two GVPM groups (i.e., in-person and telepractice)
receiving both indirect (i.e., vocal education and hygiene) and direct treatment (i.e., vocal
training). Both GVPM groups are being compared to a control group that only receives
indirect treatment. VoiceEvalU8 is the voice evaluation tool that the student teachers use
daily, before and after teaching all day. There are no other voice disorders prevention studies
in the literature.

Treatment studies in the voice telepractice literature have focused on patients with
Parkinson’s disease, vocal fold nodules, muscle tension dysphonia, and other voice
disorders. Patients with Parkinson’s disease received Lee Silverman Voice Treatment either
through in-person or telepractice services. Results indicated no difference in treatment
outcomes across in-person and telepractice methods (Constantinescu et al., 2011; Howell,
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Tripoliti, & Pring, 2009; Tindall, Huebner, Stemple, & Kleinert, 2008). Treatment for vocal
fold nodules, muscle tension dysphonia, and other disorders delivered either by in-person or
telepractice methods yielded no differences in outcomes (Fu, Theodoros, & Ward, 2015;
Mashima et al., 2003; Rangarathnam et al., 2015). The treatment of paradoxical vocal cord
dysfunction delivered via telepractice facilitated successful treatment outcomes and a first
month cost savings of $2,376.72 (Towey, 2012a). A head-and-neck cancer speech-language
pathology specialist program compared standard care (i.e., phone/e-mail support and in-
person appointments with a specialist) to telepractice (i.e., online consultation between
specialist, treating clinician, and client; Burns, Kularatna, et al., 2017; Burns, Ward, et al.,
2017). Results indicated that the number and duration of services were significantly reduced
in the telepractice condition and that the client and clinician satisfaction of services was
higher in the telepractice condition.
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In summary, evidence exists to support the use of telepractice as a successful method of

service delivery for the assessment, prevention, and treatment of voice disorders. This article
presents considerations for building a voice telepractice program by discussing licensure
requirements, describing federal and state laws, outlining reimbursement, suggesting
documentation needs, and identifying tele-practice methods.

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Licensure
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To conduct telepractice within the United States across states, practitioners are required to be
licensed in the state where they are physically located and in the state where the client is
physically located. Here is an example. A potential client contacts a clinician for voice
therapy after reading about the services provided on the clinician’s private practice website.
The private practice is focused on transgender voice care. The client lives in Florida, and the
clinician’s private practice is located in Pennsylvania. To work with this client, the clinician
will need to be licensed in Pennsylvania and Florida. The clinician holds and maintains a
license in Pennsylvania, but not in Florida. To inquire about the requirements for a Florida
license, the clinician visits ASHA’s practice portal on telepractice and clicks on “ASHA
State-by-State” (ASHA, 2018b). Once on the site, the clinician clicks on “Florida” and
learns that reciprocity of the speech-language pathology license exists between Pennsylvania
and Florida. After reading ASHA’s practice portal, the clinician verifies the requirements to
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qualify for the license on Florida’s Board of Speech-Language Pathology and Audiology
website.

Maintaining multiple licenses is not new to the profession, especially for practitioners who
live and work close to other state borders; however, with the expanding reach of technology,
the need to hold multiple licenses for tele-practice as a delivery method magnifies the issue.
There is a need for license portability. The American Medical Association introduced the
Interstate Medical Licensure Compact. A physician must hold a license in the state of
principal license. The state of the principal license is determined by the state “in which the
physician resides, the state where at least 25% of the practice of medicine occurs, the
location of the physician’s employer, or if no state qualifies, then the state designated as
state of residence for purpose of federal income tax” (American Medical Association, 2018).
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With the identification of the state of the principal license, the physician may practice in 20
states with five states that have Interstate Medical Licensure Compact legislation pending.
No need to seek licenses in multiple states. Nurses and physical therapists currently have
interstate compact legislation in 20 states for nurses and five states for physical therapists.
The American Occupational Therapy Association and ASHA are in the developmental
stages of an interstate compact (ASHA, 2018c). Until ASHA supports and lobbies for
interstate compact license legislation, SLPs are bound to hold and maintain licenses in the
state where both the SLP and the client are physically located.

There is one exception for the state license requirement. If a clinician works for a federal
agency (e.g., Department of Veterans Affairs [VA] and Department of Defense), the clinician
may not have to meet the same licensing requirements. For example, if part of the
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employment at the VA involves telepractice with other VA sites across states, the clinician
may not have to be licensed in each state. Confirm the requirements with the employer
before proceeding.

Telepractice offered internationally is not bound to state licensure requirements; however, as

a practitioner holding the certificate of clinical competence in speech-language pathology,
practitioners are expected to uphold ASHA’s Code of Ethics (ASHA, 2016a), Scope of
Practice in Speech-Language Pathology (ASHA, 2016b), and Preferred Practice Patterns for

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the Profession of Speech-Language Pathology (ASHA, 2004). If the clinician will be

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conducting international telepractice, it is important to confirm if any requirements exist in

that country for the profession of speech-language pathology. If requirements exist, the
clinician will be expected to follow those requirements. ASHA has a list of speech-language
pathology international associations (ASHA, 2018d). ASHA also has mutual recognition
agreements (MRAs) between five international speech-language pathology associations. The
associations include Canada, United Kingdom, Australia, Ireland, and New Zealand. The
MRAs allow the certificate holder from one of the five associations to seek an expedited
application and awarding of the certificate. The MRA recognizes that the standards met for
certification in the home association may meet all or some of the standards in the other
association; however, the MRA does not automatically grant certification by the other
associations. For example, a clinician wants to provide telepractice services to clients in
New Zealand. ASHA has an MRA with New Zealand; therefore, the clinician will need to
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apply for membership in the New Zealand Speech-Language Therapists’ Association

(NZSTA, 2018). The clinician needs to be aware of all of the policies and regulations for
membership in the NZSTA. The application for membership requires the following: a $625
application fee; letter in good standing from the home association; certified evidence of 1
year of supervised clinical experience in speech-language pathology; certified evidence of
1,000 hr of speech-language therapy practice within the past 5 years; if the master’s degree
was earned prior to 1998, then evidence in dysphagia through specific courses or previous
experience is necessary; and resume/curriculum vita of work experience. At first glance, the
MRA suggests ease of access to membership in one of the five associations; however, after
reading the application requirements, it appears that New Zealand requires additional
documentation beyond the certificate of clinical competence in speech-language pathology
from ASHA. Perhaps, the NZSTA recognizes that telepractice conducted by international
SLPs may be a threat to local NZSTA members.
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Telesupervision of clinical fellows, student interns, and support personnel also has state
guidance recommendations or regulations. A majority of states do not have regulations;
therefore, the practitioner is advised to contact the specific state licensure board. In some
states, telesupervision is not permitted. ASHA (2018e) has information about
telesupervision in specific states. Please see the telepractice practice portal under “Licensure
and Teacher Certification.”

Laws
Because of the variability of state laws regulating telepractice, it is up to the practitioner to
abide by all state regulations. Most states recognize ASHA’s scope of practice related to
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telepractice; however, some states restrict services. For example, Montana and Kentucky
require in-person evaluations. Delaware and Texas require some in-person therapy, and
Wyoming requires some in-person therapy and in-person evaluation. Additional
requirements per practice setting may be required. For example, a practitioner working in a
school setting may have to obtain teacher certification in addition to state license. Contact
the state’s Department of Education and the licensure board to verify the requirements to
practice in a school setting via telepractice.

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The following federal laws that apply to in-person services also apply to telepractice: the
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Health Insurance Portability and Accountability Act of 1996 (HIPAA), Health Information
Technology for Economic and Clinical Health Act of 2009 (HITECH), and the Family
Educational Rights and Privacy Act of 1974 (FERPA). HIPAA regulates the protection of
patient health information. HITECH was created to stimulate the adoption and protection of
electronic-protected health information (ePHI). HITECH supplements HIPAA by the
addition of electronic records in a digital age. FERPA regulates the protection of student
education records. FERPA gives parents certain rights to their child’s education records up
until the age of 18 years. At that time, the rights transfer to the student.

The bottom line is that practitioners are expected to protect the privacy and security of
client’s patient health information, ePHI, and educational records at all times. A technology
or software program used for telepractice cannot guarantee that it is HIPAA, FERPA, or
HITECH compliant because the practitioner who uses the technology or program determines
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the effectiveness of the protection of privacy and security measures. Privacy and security are
not products, but rather a process. That means that the practitioner engaged in telepractice
must develop policies and procedures to ensure protection of privacy and security. As the
clinician drafts policies and procedures, consider the following technical safeguards from
HIPAA and summarized by ASHA (2018f): (a) access control, (b) audit controls, (c)
integrity, (d) person or entity authentication, and (e) transmission security. Information in the
Appendix is from ASHA’s (2018f) website on HIPAA Security Technical Safeguards with
examples of implementation. The specific safeguards are noted with “required” or
“addressable.” Addressable means that the practitioner must determine the need for the
specification.

Within the policies and procedures manual, the practitioner must indicate when periodic
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review of the technical safeguards occurs to determine any risks. If changes are made, based
on the review, then indicate that in the policies and procedures manual and update the
relevant standards. In addition, the practitioner needs to continually seek training for himself
or herself and all staff members regarding privacy and security standards and apply
appropriate sanctions when policies and procedures are violated. Training procedures must
also be documented in the policies and procedures manual. Common HIPAA mistakes
include being unprotected from hacking by not following HIPAA technical safeguards for
access controls and transmission security, inadequate HIPAA training, and failure to conduct
a periodic review of risk analysis (HIPAA Journal, 2017). The U.S. Department of Health
and Human Services and the U.S. Department of Education offer free HIPAA and FERPA
training.
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To ease concerns about HIPAA, there is an option to sign a Business Associate Agreement
(BAA) with the videoconferencing platform for synchronous services. The BAA would put
the responsibility back on the platform provider for protecting patient information and
reporting security breaches involving ePHI. Of course, the BAA is not free. The provider
will charge a fee. For example, VSee charges $299 per month for the BAA. Zoom requires
spending a minimum of $200 per month to qualify for the BAA. Interestingly, Zoom still
meets the necessary HIPAA specifications for access control, audit controls, integrity, person
or entity authentication, and transmission security without spending the additional money to

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qualify for the BAA. Zoom’s information about meeting HIPAA standards can be accessed
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online at https://zoom.us/healthcare.

Reimbursement
Options for telepractice reimbursement include private insurance, Medicaid, and private pay.
Medicare reimburses for some telemedicine and telehealth services; however, Medicare does
not reimburse for telerehabilitation of which telepractice by SLPs and audiologists fall
under. ASHA, along with other organizations, is advocating to expand eligibility to SLPs,
audiologists, and other habilitation/rehabilitation professions. Some states have passed
insurance parity laws mandating that private insurance must cover telepractice services. The
parity laws require that private insurance and health maintenance organizations must
reimburse telepractice services at the same rate as in-person services. If the state does not
have a parity law, insurers may reimburse for telepractice services. Given the amount of
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variability across states and within states for insurance coverage, practitioners are
encouraged to first check with the payer and state regulations before conducting services.

Medicaid is a federal/state entitlement program for low-income adults, children, pregnant

women, older adults, and people with disabilities. Medicaid is administered by states and
funded by both states and the federal government. Each state administers its own program
under federal guidelines; adheres to eligibility requirements; elects to pursue additional
options for coverage and may choose to cover other groups outside the federal guidelines;
determines type, amount, duration, and scope of service; and sets the payment for services
(ASHA, 2018g; Medicaid, 2018). Coverage of Medicaid telepractice services is determined
by each state. Practitioners are encouraged to contact the state Medicaid office to verify
coverage of telepractice services and any additional codes or documentation that are needed
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for reimbursement. ASHA provides state-by-state maps for reimbursement laws and
regulations in the telepractice practice portal. For private pay, the client pays for telepractice
services directly to the practitioner. The practitioner determines the rate for the service.

Documentation
Under the Laws section of this article, a telepractice policies and procedures manual was
discussed to include HIPAA technical safeguards. Policies and procedures for HIPAA
technical safeguards are one part of the manual. The manual should also include a general
definition of telepractice with explanations of synchronous, asynchronous, and hybrid
approaches. Procedures should be clear on how clients are informed of telepractice services
and eligibility for such services. For example, “the patient is informed, verbally and in
writing, about telepractice, at the time of the initial visit when telepractice is discussed and
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at the start of the first telepractice visit” (Towey, 2018). The practitioner should know the
state law requirements for informed consent. For example, Medicaid requires informed
consent in 27 states. A consent form should be drafted at an appropriate reading level for the
client to understand. The client reads the consent; the practitioner verbally describes the
services with an opportunity for questions and answers; and if the client accepts the services,
then the client should sign the consent. The consent informs the client about telepractice,
why telepractice is recommended, privacy and security measures taken by the practitioner to

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protect ePHI, privacy and confidentiality protection by the client to avoid a public place or
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limit audio information in public, and type of equipment used.

The manual should also include how telepractice services are documented. An example of
what to include in an assessment/treatment session note is provided below. Documentation
for each session should include time spent with the client, Current Procedural Terminology
code for service, any modifiers, the GT (synchronous telepractice) modifier, which indicates
synchronous telepractice and/or the GQ modifier, which indicates asynchronous telepractice,
and physical location of the client and the clinician. A statement that the client was informed
about the use of telepractice, as described in the policies and procedures manual, should be
included in the note. If someone is observing the session or participating in the session as a
communication partner or ehelper, then the documentation should acknowledge that the
client gave consent and that the role of the person should be described. The note should
indicate the synchronous provider (e.g., Zoom) and the method for exchange of
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asynchronous materials. Documentation should indicate the video/audio quality and

connectivity during the synchronous session. Documentation should continue in the typical
manner used for prevention, assessment, and treatment sessions for the rest of the note.

Method
Technology
Technology considerations should involve requirements necessary for the clinician and the
client. Traditionally, a computer, either laptop or desktop, with an internal or external
webcam is necessary for both parties to meet synchronously online in a videoconferencing
platform. More recently, some videoconferencing platforms are also supported on
smartphones and tablets. For example, Zoom supports iOS and Android operating systems.
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In addition to the webcam or camera on the device, audio requirements are also important.
The client and the clinician may use the internal microphone and speaker on the device or an
external microphone and speaker. External microphone options include standing
microphones, headset microphones with or without speakers, and ear buds.

Selecting the videoconferencing platform for synchronous telepractice is arguably the most
important piece to the technology component of building a successful voice telepractice
program. There are many options available. FaceTime, Skype, and Google Hangouts are
videoconferencing platforms, but they do not offer privacy and security features required by
HIPAA. Other videoconferencing platforms are available that consider HIPAA standards.
Examples of such platforms include Zoom, VSee, ooVoo, Bluejeans, doxy.me, Cisco Webex,
and so forth. According to a recent survey of synchronous technology used by practicing
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telepractice clinicians, Webex (42%) and Zoom (35%) were the most common platforms
(Grillo, 2017b). At a minimum, the videoconferencing platform should allow screen share,
allow recording of sessions to a local computer for later use in asynchronous activities,
optimize bandwidth based on the client and the clinician’s network with automatic adjusting
for video and audio quality when bandwidth slows, encrypt transmission of information,
never have access to ePHI, and not store information that is transmitted.

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For asynchronous materials, clients and clinicians can share Google Drive, Docs, or
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Dropbox for assignments and create private YouTube channels. All of these shared platforms
are free and password protected. The only people who will have access to them are the client
and the clinician. The use of these platforms must also be accounted for in the policies and
procedures manual. Under access controls, indicate that the asynchronous materials are
accessed through password-protected accounts. In addition, the materials are shared only
with the client and the clinician. Under integrity, indicate that the materials shared in the
clinician’s account are destroyed after patient discharge. The client may elect to keep the
materials for later use. According to a recent survey of practicing telepractice clinicians,
asynchronous activities were typically offered through e-mail (73%), recorded videos (38%),
and custom programs (20%; Grillo, 2017b). The activities involved homework (81%),
recording speech samples (31%), and recording communication interactions (27%).

Four examples of asynchronous materials related to voice are presented next. In Example 1,
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the client’s assignment for the week is to complete a daily voice therapy practice chart. The
clinician shares the chart with the client through Google Drive, Docs, or Dropbox. The client
completes the chart every day for a week. When the client returns for the following weekly
appointment, the client and the clinician can access the chart together online with screen
share to discuss the assignment. A daily voice therapy practice chart is one example. Others
include a weekly vocal hygiene chart and a daily vocal warm-up chart. It is important not to
bombard the client with too many charts, but rather focus on the ones that matter most to the
client and the ones that the client will likely complete. If the client is not interested in
completing charts, then abandon the option. Perhaps, paper-based assignments are not
necessary. The work should focus more on changing the client’s vocal output. In Example 2,
the clinician edits a small portion of a previously recorded synchronous session through
Camtasia, a video editing software, to highlight 30 s of the client’s “new” voice for one-on-
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one conversation. The edited sample is then shared with the client through Google Drive or
Dropbox or a private YouTube channel. The client may then download the sample to a
mobile device. Throughout the day, the client may refer to the recording to be reminded of
the new voice (see Supplemental Material S1). Another video is edited for the client
demonstrating her use of the new voice for one-on-one conversation and oral twang for
healthy projected voice over noise (see Supplemental Material S2). She can refer to the
video as an example of switching between the two voices. In Example 3, another option is to
have the client record audio/video examples using the new voice in connected speech
throughout the day and sharing the recordings with the clinician during the synchronous
session or asynchronously via Google Drive or Dropbox. Feedback may be given in real
time during the synchronous session or through e-mail after the clinician reviews the
recordings asynchronously. In Example 4, the clinician asks the client to record sentences
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and memorized speech acts (e.g., pledge of allegiance) switching between her “old” voice
(i.e., the voice before therapy) and new voice (i.e., learned through therapy) on her
smartphone by Friday at 5 p.m. (see Supplemental Material S3). The client uploads the
recording to Google Drive to share with the clinician. The clinician accesses the recording
and provides feedback to the client in an e-mail before the next treatment session. All of
these examples work for both adults and children. For children, materials are shared between
the clinician and the caregiver.

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Digital Materials
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For synchronous methods, materials must be adapted to the videoconferencing framework.

For adults and older children, a premade list of phrases, sentences, conversational, topics,
and so forth may be presented in a document that is shared between the client and the
clinician. In addition, during the session, the clinician may use the chat function to provide
feedback to the client while the client is talking. The client reads the feedback and makes
adjustments without the clinician interrupting the flow of speech (see Figure 1). To train
discrimination of new and old voice patterns, another option is to have the client or the
clinician switch from an old, vocally abusive voice pattern to a new, vocally healthy voice
pattern. The client or the clinician would use the chat function and discriminate between the
two by typing “new” or “old” for each presentation of the voices (see Figure 1). Rather than
using the premade list of phrases, sentences, and so forth, as seen in Figure 1 (Grillo, 2018),
the clinician may create more visually appealing materials on slides in Microsoft’s
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PowerPoint. These materials may be used to elicit various levels of a treatment hierarchy
and apply the concept of negative practice (i.e., new vs. old voice) to voice therapy (Grillo,
2012, 2017a). Figure 2 (Grillo, 2018) is used to elicit voice work at short phrase and
sentence level, whereas Figure 3 (Grillo, 2018) is demonstrating the monologue level
(Grillo, 2012, 2017a). Figure 4 is used to elicit the specific spontaneous speech act level of
the hierarchy with incorporation of negative practice (Grillo, 2012, 2017a).

Use of Client’s Environment and Communication Partners

One of the major advantages of telepractice is the opportunity to provide services in the
client’s environment where he or she lives, works, and plays. Telepractice inherently
supports functional assessment and treatment goals that are immediately trialed in the
client’s environment. Use of the environment may occur synchronously, as reported by 60%
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of clinicians using telepractice and asynchronously, as reported by 29% of clinicians using

telepractice (Grillo, 2017b). According to clinicians who use telepractice, responses suggest
that the environment is used more for treatment rather than assessment (Grillo, 2017b).
Voice therapy can be conducted in the client’s place of residence, work place, performance
space, educational setting, and caregiver or friend’s home, just to name a few. As the client
progresses in therapy, the clinician may consider adjusting where therapy is conducted. For
example, a teacher with a voice disorder is working with a clinician via telepractice. Voice
therapy began in the teacher’s home 3 weeks ago. The teacher has progressed well through
voice therapy producing multiple new voice options in connected speech to meet her daily
occupational and social needs (Grillo, 2017a). The clinician wants to assess generalization
of the new voices to the classroom. Synchronously, a telepractice session is conducted
before or after the client teaches for the day in her classroom. The client is physically in the
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classroom, and the clinician is present remotely through videoconferencing. No students are
in the room. The clinician asks the client to position the webcam or device’s camera in the
center of the room so that the clinician can see the teacher move around the room and
perform various teaching activities with speech. Under the direction of the clinician, the
client switches from one new voice to the next in connected speech, as she completes the
activities. The clinician and the client discuss her performance and offer opportunities for
continued practice and client self-monitoring throughout the session. Telepractice allows for
treatment in the client’s functional environment. A similar scenario can occur with a

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performer on his or her typical performance stage, a lawyer in his or her typical courtroom, a
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resident in his or her cafeteria, a physician in his or her typical exam room, and a child in his
or her classroom, just to name a few, as long as privacy and security standards and facility
policies are considered.

The client’s environment may also be used asynchronously. The VoiceEvalU8 app, server,
and web portal measure acoustic, perceptual, and aerodynamic data twice a day in the
client’s environment (Grillo, 2017a). The app records the measures from the client’s
smartphone or tablet, which then connects to a server that performs the analysis and stores
the data for the clinician to access via the web portal. VoiceEvalU8 promotes the ability to
conduct real-world clinical investigations of voice beyond the typical pretreatment and
posttreatment data collection “snapshots” to a longitudinal repeated-measures “landscape.”
That landscape can be used as a baseline assessment, progress monitoring during therapy,
posttreatment assessment, and maintenance monitoring after the conclusion of voice therapy.
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In addition, other apps provide real-time feedback to the client regarding voice use in the
client’s environment (home, school, restaurant, stage, etc.; Van Stan, Mehta, Petit, et al.,
2017; Van Stan, Mehta, Sternad, et al., 2017). That feedback may also be shared with the
clinician. The clinician may access the feedback results asynchronously to check client
progress. In addition, the clinician may ask the client to record a communication interaction
with the client’s smartphone in the client’s functional environment and either review it
together synchronously or the client sends the audio to the clinician and the clinician reviews
it asynchronously and provides feedback in an e-mail before the next session.

A second major advantage to telepractice services is the involvement of communication

partners. Because the services are provided in the client’s functional environment, it is
expected that communication partners will be involved. Clinicians who use telepractice
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reported that the most common communicative partners were caregivers (59%), ehelpers
(48%), other (30%), children (19%), spouses (17%), and grandparents (15%; Grillo, 2017b).
Other communicative partners included parents, teachers, coworkers, instructional aides, and
classmates. An ehelper is present at the client’s physical site to assist the client. It is the
responsibility of the clinician to ensure that the ehelper is appropriately trained. The ehelper
may be a teacher’s aide, nursing assistant, student clinician, speech-language pathology
assistant, caregiver, or family member, just to name a few. Clinicians who use telepractice
reported that use of a communication partner included assistance with technology (85%),
generalization of newly learning behaviors (73%), practice of new learning behaviors (67%),
homework (58%), direct intervention (30%), and assistance with assessment (26%; Grillo,
2017b).
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Involving a communication partner in the client’s environment will support the

generalization and carryover of newly learned voice behaviors. For example, a client’s
husband is invited to join the synchronous session after the client grants permission. The
clinician asks the client to describe what she is learning in therapy to the husband. This is a
great opportunity for the clinician to assess the client’s knowledge of therapy goals. The
client demonstrates all of the new voices she has learned and contrasts them with her old
voice. Her husband is asked if he hears a difference. To continue the goal, the clinician
facilitates a discrimination task in which the client produces 10 sentences and the husband

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needs to guess what voice was used in each sentence. Another option later in the session or
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at the next session is to have the client and the husband discuss specific conversational topics
together. The client must switch between the newly trained voice patterns and contrast them
with the old voice. The husband will hold up an index card that corresponds to the voice that
is being produced. The client will nod in agreement or indicate an incorrect choice. The
clinician is facilitating the exchange and offering feedback to both the client and the
husband. This same type of exchange may occur between other communication partners, for
example, child client and instructional aide, groups of child clients working together with an
ehelper, resident of a long-term care facility and nursing aide, adult client and friend, and so
forth.

Conclusions
Telepractice service delivery will continue to expand. In the future, that expansion will
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skyrocket if an interstate license compact is adopted for ASHA with successful legislation at
the state level and if Medicare reimburses for telepractice; therefore, SLPs need to be
prepared to build successful telepractice programs. General information about telepractice
was provided in this article with specific considerations for clinicians interested in voice.
Clinicians need to be aware of the current voice telepractice literature, cognizant of licensure
requirements and state and federal laws, vested in protecting the privacy and security of
client ePHI, attuned to documentation needs, informed about reimbursement, and engaged in
the creation of methods that match the functional nature of telepractice service delivery at a
distance.

Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
A special thanks is given to the following graduate students: Elizabeth Alderfer, Savanna Asta, Kay Bogunovich,
Caitlin Boyle, Kathryn Coleman, Rachel Eyler, Elizabeth Fedak, Ali Graham, Melanie Iuliano, Kristen Kaelin,
Kelly Kurnz, Abbie Lookingbill, Allison Lumbis, Amelia Lynch, Kaeli MacArthur, Natalie McGonigle, Sarah
Moreau, Hannah Symons, Alicia Tomkowich, and Carly Witkowski. Without student involvement, the work
supported by grant NIDCD R15DC014566 would not be possible. The author would like to thank Michael Towey
and the telepractice staff at Waldo County General Hospital in Belfast, Maine, for running a content-rich and
application-based speech telepractice training program.

Financial: Elizabeth Grillo is an employee of West Chester University and receives a salary. She also receives
royalties for online continuing education courses through Northern Speech Services. Grillo’s research is funded by
the National Institute on Deafness and Other Communication Disorders Grant R15DC014566.

Nonfinancial: Elizabeth Grillo is the inventor of the Global Voice Prevention and Therapy Model and the
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VoiceEvalU8 application, server, and web portal. She uses Zoom, a web-based videoconferencing platform, for
synchronous telepractice and Desire 2 Learn, an academic computing software, for asynchronous telepractice.

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Appendix
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Health Insurance Portability and Accountability Act of 1996 Security Technical Safeguards
as Summarized by the American Speech-Language-Hearing Association

1. Access control: “Allow access to ePHI only to those persons or software programs that have been granted access
rights.”
• Unique user identification (Required). This would be a username and password to enter the program.
• Emergency access procedure (Required). For example, if the power is out, then the telepractice session will not
function until the power is restored.
• Automatic log off of systems (Addressable).
• Encryption and decryption of ePHI (Addressable). The practitioner may purchase encryption software. In the
Breach Notification Final Rule (U.S. Department of Health and Human Services, 2009), ePHI must be “rendered
unusable, unreadable, or indecipherable to unauthorized individuals.” Encryption is the primary method for achieving
this. There is no specific recommendation for encryption strength.
2. Audit controls: “Hardware, software, or procedural mechanisms to record and examine all ePHI activity.”
• No implementation specifications. Data storage is important to consider. Consider vendors who do not store
information on the vendor’s site. For example, Zoom, an online, synchronous videoconferencing software program,
does not store session information on its site. If the practitioner wants to record the session for asynchronous use, then
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he or she may do that to his or her password-protected, encrypted local computer. If the system is breached, what are the
policies for breach notification?
3. Integrity: “Protect ePHI from being altered or destroyed improperly.”
• Confirm that ePHI has not been altered or destroyed in an unauthorized way (Addressable). In the policies and
procedures manual, indicate when materials are deleted, perhaps at the time of client discharge.
4. Person or entity authentication: “Must verify that a person who wants access to ePHI is the person they say they are.”
• No implementation specifications. Username- and password-required systems would help guard against this.
Clinicians and clients should not share usernames and passwords with other individuals.
5. Transmission security: “Must guard against unauthorized access to ePHI that is transmitted electronically.”
• Protect ePHI from being altered without detection (Addressable).
• Encrypt ePHI whenever deemed appropriate (Addressable).
• Does the vendor run third-party accreditation and independent audits to validate security?
• When a breach occurs, breach notification letters must be sent to all affected individuals advising them of the
breach.

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Figure 1.
Screenshot of a telepractice-synchronous session (Grillo, 2018) with screen share, chat
function, and web camera turned on for the clinician. During the synchronous session, both
the client’s and the clinician’s web cameras can be displayed simultaneously. For this screen
shot, only the clinician’s web camera is shown to protect client privacy. The screenshot
example displays all of the comments from the clinician at once. Typically, the client would
see one comment at a time as the clinician types them in real time. Screenshot reprinted with
permission from Kay Bogunovich.
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Figure 2.
Screenshot of a Microsoft PowerPoint slide eliciting short phrases/sentences (Grillo, 2018).
The client would be instructed to say the phrases in his or her “new” voice. Reprinted with
permission.
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Figure 3.
Screenshot of a Microsoft PowerPoint slide eliciting monologue (Grillo, 2018). Reprinted
with permission.
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Figure 4.
Screenshot of a Microsoft PowerPoint slide eliciting a specific spontaneous speech act with
incorporation of negative practice. Reprinted with permission.
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