by Gordy Slack
Alexander Graham Bell spent much of his life teaching deaf children while seeking ways to help the hard of hearing. Today, the high-tech descendants of his most important invention, the telephone, are continuing in that vein, being deployed in Northern California by the UC Davis Medical Center’s California Tele-Audiology Program (CTP) to help address hearing loss among newborns in rural areas. The CTP employs telemedicine to conduct hearing examinations on children who would otherwise not get them and to identify babies who need medical interventions that can improve their lives.
The California Department of Health Care Services mandates that each newborn baby get a hearing screen before leaving the hospital. If the screen reveals potential problems, parents are asked to bring their baby to an audiology center within a few days. However, pediatric audiologists that are qualified to do these follow-ups are rare outside the city. In fact, north of Sacramento there are no pediatric audiologists at all who can evaluate infants with Medi-Cal or no insurance. To follow their doctor’s advice, the parents often have to bring their baby hundreds of miles to get those follow-up hearing tests. Many parents simply cannot.
The rural Northern California region (composed of Shasta, Glenn, Butte, Trinity, Tehama, Lassen, Modoc, and Siskiyou counties) is the most problematic in California when it comes to these follow-up exams, says Anne Simon, the clinician who conducts the remote tests for the CTP. “As many as 40 percent of newborns who should come in for a second test never do,” Simon says. Given the obstacles faced by these families, it is not surprising. In some cases, parents would have to take off work, driving for many hours in each direction. Other parents postpone the testing and then forget. Or they just decide to skip it and hope for the best.
The costs of such no-shows can be profound for the patient, their family, and society. Detected early on, hearing problems can often be addressed with simple procedures or hearing aids. “If an intervention takes place within six months of birth, a child with serious hearing loss may well develop speech and language similar to their hearing peers,” says Simon, a senior pediatric audiologist in the UC Davis Department of Otolaryngology. But if no intervention is made, “even mild hearing loss can affect speech and language development, academic achievement, and can have a profound influence on a child’s life and the family’s life,” she says.
“If you look at it from a dollars and cents perspective—the added education, speech-language pathologies, special classes, lost-work productivity— each hearing impaired child who is not identified [in the first six months] costs up to one million dollars,” says Dr. James Marcin, Director of Pediatric Telemedicine at UC Davis Children’s Hospital. “You can save that amount of money—and a lot of suffering—by identifying and treating a child early,” Marcin says.
To make it easier for parents in faraway parts of Northern California to comply, CTP gives them the option to conduct secondary and tertiary exams remotely, aided by telemedicine technologies. Instead of driving several hours to Sacramento or Oakland, patients can go instead to nearby Mercy Medical Center in Redding, where EEG technicians act as Simon’s “hands,” giving her assistance while she conducts the technical parts of the tests via the California Telehealth Network (CTN) from 200 miles away.
Unlike other teleaudiology programs that perform limited testing, CTP specialists actually perform a complete hearing evaluation and make a diagnosis remotely.
“All of the tests that I would conduct in person,” says Simon, “I am doing remotely through the CTN. Although the audiology equipment we use is in most ways standard, it has been modified so I can log onto it and control it remotely with my PC in Davis.”
The technicians in Redding set up the equipment and provide a human touch to patients. This, says Simon, can make a big difference when parents are worried about their babies or are receiving frightening news about their newborn’s hearing.
Over the CTN, Simon conducts six tests. First, the auditory brainstem response evaluates the threshold at which a person hears at various frequencies. Simon also conducts video otoscopy, which uses a camera-equipped examination tool to look in the patient’s ear canals. She also performs otoacoustic emission tests that examine the functionality of the hair cells in the cochlea. Simon examines the patient’s face and outer ear for signs of trouble. Finally, Simon conducts a tympanometry test measuring how well the patient’s eardrum is moving.
The examinations are just as thorough as they would be if conducted in person. But they do have one drawback; they take a lot longer to execute. “The excellent EEG technicians who help out in Redding are not as experienced setting up the examination equipment,” says Simon. “And it can be difficult to apply instruments exactly right to infant-size ears.”
Bandwidth is not yet sufficient to instantaneously transfer super-high-resolution video images of the ear drum, so that test also takes longer through the network than it does in person. Also, if she is in the room with a patient, Simon naturally examines the ears and face of her patients while she conducts other tests. But when she is not physically there, those tests must be done more deliberately, which takes extra time. In person it is possible to make progress even while a patient is crying. In a telemedicine session, however, an unhappy baby can grind things to a halt by making communication impossible.
All of the delays combined can more than triple the time it takes to conduct a full examination, Simon says. A typical in-office visit may take 2.5 hours. The tele-visits can take up to 8 hours.
A $50,000 CITRIS seed grant given to CTP earlier this year should speed things up by customizing the audiology tools for the telehealth environment, says Marcin. Collaborating on the project is UC Berkeley engineer Gerald Friedland, senior research scientist at the International Computer Science Institute. Friedland hopes to find ways to allow Simon to quickly fit otoscopes and hearing aids during telemedicine sessions, for example, and to speed the transfer of large amounts of data, like the videos of the eardrum. He also hopes to create software interfaces that make the examinations more efficient to conduct remotely.
In the past three years, the CTP has cut the failure-to-show rate in Northern California from 40 percent to zero, says Marcin. The pieces are in place for a tele-audiology program that vastly improves access to healthcare for remote populations at the same time as conserving societal resources and saving time and money for patients. If new technology from Friedland’s lab can make it more efficient and easier to copy, the CTP could quickly become a model for similar programs around the state and the world.