By Gregg D. Givens, Jianchu Jason Yao, and Daoyuan Yao
Disruptive innovation often allows a new population of consumers to have access to a product or service that previously could not access the product or service (2). However, the dilemma of disruptive innovation frequently lies within the inventors who know there is a place for their vision yet the industry and/or profession may not realize it. This can occur in business, manufacturing, and even health care. The innovation projects that the authors have developed in the Teleaudiology and Engineering laboratory at East Carolina University for the past 15 years have resulted in such disruptions. Our goal has been to provide hearing health care to individuals who do not have access to an audiology professional because of geography, lack of technology, or monetary reasons. Telepractice in the field of audiology exists in a relatively primitive fashion. Currently, telepractice techniques exist with storing and forwarding of patient information as well as limited remote observation of ongoing audiological evaluation or treatment. It is estimated that less than 50 audiologists use some form of telepractice within the US. This low occurrence exists even though teleaudiology has the potential to meet the great need to serve those without hearing health care. This further serves as motivation to those in our laboratory to solve this issue.
Need For Teleaudiology
Many groups are underserved regarding their hearing health care; among them are individuals in rural areas, underdeveloped countries, senior citizens with no transportation, military personnel, and prisoners. Most recently, statistics indicate that approximately a third of the US military personnel returned from the Middle East with some level of hearing loss due to unavoidable blast exposure. Although periodic hearing assessment is usually scheduled for these troop members, their services are often backlogged as a result of insufficient access to audiology specialists and facilities. Furthermore, according to the National Institutes of Health, roughly one third of Americans over 60 years of age and 50% of those over 75 years of age have hearing loss in the US. It is estimated that by the year 2030 there will be 73 million individuals with hearing impairment in this country alone. These numbers will cause a tremendous demand in related hearing health care. The increased attention to telehealth and the advances in technology have led to an evolution of novel approaches toward the development and implementation of teleaudiology systems.
Teleaudiology System Development
At East Carolina University, we have proposed a new approach using a cloud-based, distributed system to support remote hearing testing and diagnosis. The system network follows browser–server architecture. The system consists of three sites: A server hosting the database and the application software that coordinates all the data exchange, storage, and information display. The patient and the audiologist both connect to the server via the Internet. The patient uses a provided audiometer, which connects to the Internet with a computer or other gateway device. The audiologist logs into the server using an Internet browsing device. Since all the required software is hosted by the application server, the resulted “thin” client minimizes hardware and software requirements on the audiologist’s Internet browsing device.
Software maintenance and data management are therefore separated from the clinic settings, thus bringing great convenience to the audiology professionals. Due to the minimal bandwidth requirement, regular data service subscription from commercial Internet server providers is sufficient for the remote hearing test with the proposed system. Thanks to the three-tier software design paradigm, the system is scalable to include pure tone audiometry, speech audiometry, tympanometry, and otoacoustic emissions (OAE). Since testing data are stored in a database on the server, they can be potentially integrated into existing electronic medical records, meeting the standards established for today’s medical informatics.
With the proposed system, an audiologist can perform pure tone and speech tests by selecting corresponding tabs on a webpage. Through this page, the audiologist can also choose the type of transducer (air or bone conduction) as well as which ear to administer the sound. Stimulus can be selected between continuous and pulsed tones. By activating the “Stimulus” button, the audiologist sends the testing command to the patient audiometer. The system server then relays the response of the patient as the result of a button push or verbal response. The audiologist and the patient can talk to each other via the video interface embedded in the system.
Experimental results have demonstrated that the remote hearing assessment is equivalent to its traditional counterparts and more efficient than other remote systems currently developed. Neither the audiologist nor the patient is limited by their geographical location because of the distributed nature of the system. This unique system does not involve complicated patient interference and makes hearing test services more accessible to traditionally underserved patient groups.
Expanse Of Disruption/Solutions
While evaluation results from our pilot tests are positive, the system created at the Teleaudiology and Engineering laboratory at East Carolina University has been slow in acceptance, possibly due to several barriers of interruption. The disruption that has occurred is reflected in a broad spectrum of challenges in areas of technology, clinical practice, reimbursement, and licensure.
While “disruptive innovation” typically refers to the eventual disturbing impact on the intended business, interesting technological “disruptions” were observed during the course of our design and test.
When the authors’ group was pilot testing the system at a local ear, nose, and throat (ENT) medical facility, the Bluetooth gateway device utilized in the prototype, instead of connecting to the assigned teleaudiometer, actively established telemetry to a hearing aid programming device that existed in the medical facility. This resulted in a disruption to their regular clinical services. This incidence was resolved by reconfiguring the gateway device to prevent future connection to unintended Bluetooth addresses.
Another area of technical challenge is related to the speed of the system. In order to create a useful system, the technology must present the auditory stimulus to the patient and return the patient responses to the examiner in as close to real time as possible; anything less than this would produce disruptions to the standard audiology testing procedure. In remote hearing tests, where data are transmitted over the Internet and routing and switching are involved, the geographically separated audiologist and patient may unfortunately experience some level of uncertainty in their signal exchanges. Carefully designed interactions between the server and the remote gateway and audiometer can usually minimize the delays within an acceptable level of human perception.
Producing appropriate encryption of all signals relevant to the patients’ personal health information provided another system challenge that can potentially prevent innovation acceptance. Security of patient and audiologist information and personal health records is vital to any healthcare system. When services are provided in a remote manner, where data travel via the Internet, people are naturally more cautious and hesitate to adopt the new technology, despite the potential benefits the inventions can bring. In order to ease this concern, designers should use the right protocols for the webserver access, appropriately encrypt transmitted data, and properly define privileges assigned to individuals who need to access to the system.
On the practice side, this approach to hearing assessment is new to the professional of audiology. Traditionally audiologists see a patient in person; thus, the remote viewing of a patient is foreign to the normal routine. Audiologists have also had difficulty with the use of new technology. We have identified the need of educating our colleagues as to the new system and the benefits this may present to their offices. Some professionals have had difficulty envisioning how they could apply this system to their practice. While some practices will not need such technology, others could benefit from it greatly with regard to the saving of the professionals’ travel time to a better access to a greater population. Broens et al. noted that successful telemedicine is critically dependent on the attitudes, perceived usefulness, and acceptance of the technology by healthcare professionals and other key stakeholders such as patients and healthcare administrators. Singh et al. concluded from a survey of professionals that the majority of respondents indicated that teleaudiology is likely to have a minimal effect on the quality of hearing health care, even though many respondents indicated that teleaudiology would have a positive effect on accessibility to service. Clearly, there is much educating to do in order for the current professionals to realize the benefit of these new systems to their patients and practice.
A third area of interruption is with regard to reimbursement. This new system has interrupted the usual reimbursement system. Until recently, insurance companies and federal programs have been slow to adopt this technique as a qualified approach to hearing assessment. More than 120 pieces of legislation were introduced last year in state legislatures across the country pertaining to telehealth, indicating new efforts to show the benefits and cost savings of this approach to health care. These legislative bills are focused on mandating reimbursement of tele-health procedures in insurance and federal programs such as Medicaid. The premise is that telepractice is not a different procedure but a new tool from which standard procedures may be administered.
A fourth and significant interruption is in the area of healthcare licensure. Because of the remote access ability with our new system and others within telepractice, state and national borders can become blurred if not eliminated. The professional licensure structure in this country is based on state laws. State and national meetings are discussing these issues with little solutions at this time. An example of the issue is as follows: if a professional is licensed to practice in the state of North Carolina and remotely evaluates someone in North Dakota, then the professional must meet the licensure standards in both states including any continuing education requirements associated with the standards. This presents added cost for the professional and in some cases differing state licensure requirements. The disruption caused by advancing technology has created a dilemma between consumer protection regarding legal issues versus being able to provide health care to those who do not receive such care. Currently, the National Council of State Boards of Examiners in Speech–Language Pathology and Audiology, the American Telemedicine Association, and the American Speech–Language–Hearing Association are involved with efforts to address this issue.
All four of these areas of disruption are critical to the success of this new system and must be addressed; therefore, strategies have been created to reduce these barriers. Toward this effort, we have made a concerted effort to present new developmentand data at the state, regional, national, and international meetings. Additional efforts are focused on publishing as much as possible to place documented positive outcomes into the professional literature. Increased activity and advocacy within professional organizations is ongoing to educate colleagues as to the value of such a new approach to hearing loss assessment and management.
We have achieved an innovative development of a teleaudiology system to bring hearing health care to populations of individuals with little to no access. Yet interruptions in technology, traditional healthcare practice in the audiology field, reimbursement, and licensure have led to slow acceptance and implementation. This is consistent with what Christensen discusses in his book, The Innovator’s Dilemma, where he notes that the progress achieved by new technology is often restricted by how it is useful today and not the recognition of the developing needs for tomorrow. Companies may recognize the developing needs, yet their market analysis indicates the product may not have realistic value at the present time. Established systems in reimbursement and licensure may not react in a significant fashion until demands from the consumer and educational efforts by professional and related organizations. These are all formidable barriers, yet the innovator must remain focused on efforts to educate all involved to the benefit of the society. This strategy applies to other innovators who continue to present innovation to our professions and lives.
“This article first appeared in the journal Technology and Innovation – Journal of the National Academy of Inventors, 15, pp.253, and is reprinted by permission of the publisher Cognizant Communication Corporation (NY). Articles can be accessed online via http://www.ingentaconnect.com/content/cog/ti.”