Telehealth Technology Applications in Speech-Language Pathology

Casey Stewart Keck, MA,1 and Charles R. Doarn, MBA2

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Despite being immersed in advanced technologies and a majority

(64%)29 of Americans being connected to the Internet, the field of
1
Department of Communication Sciences and Disorders, College speech-language pathology (SLP) has been slow to utilize avail-
of Allied Health, University of Cincinnati, Cincinnati, Ohio. able technologies to expand services to individuals who would
2
Department of Family and Community Medicine, College otherwise be restricted. SLP practitioners are anxious to adopt
of Medicine, University of Cincinnati, Cincinnati, Ohio. these technologies but have encountered barriers such as limited
reimbursement, state licensure laws, and medical information
privacy laws. Moreover, SLP practitioners are confronted with
Abstract the hurdle of evolving face-to-face (FTF) clinical practices into
Introduction: Speech-language pathologists are anxious to adopt effective telehealth practice adapted to the current national
telehealth technologies but have encountered barriers such as limited infrastructure.
reimbursement, state licensure laws, and medical information pri- Telehealth service delivery models can be divided into two cate-
Telemedicine and e-Health 2014.20:653-659.

vacy laws. Moreover, speech-language pathologists are confronted gories: store-and-forward technology (asynchronous) and the use of
with the hurdle of evolving face-to-face clinical practices into ef- real-time technology (synchronous). A hybrid model is emerging,
fective telehealth practice adapted to the current national infra- and SLP practitioners are combining these two technologies to
structure. Factors such as costs, availability of resources, and overcome infrastructure shortcomings affecting the ability to make
diagnostic/intervention and patient needs should be considered when sound clinical decisions.5,7,11–13,20,21,25–28 Telehealth infrastructure
selecting the telehealth infrastructure for service delivery. Under- encompasses connectivity (how telecommunications are accessed)
standing the new role of technology in the diagnosis and treatment of and equipment (what devices are used to enable telecommunica-
communication disorders is vital for the expansion of telehealth as a tions). Internet-based videoconferencing software enables two-way
standard of care. The purpose of this article is to overview the audio and video communication and is currently the primary syn-
current technologic infrastructure and procedures for telehealth chronous method.30 However, factors such as costs, availability of
applications in speech-language pathology (SLP) and the innate resources, and diagnostic/intervention and patient needs should be
challenges and opportunities. Materials and Methods: A literature considered when selecting the telehealth infrastructure for service
search was conducted for telehealth publications in the field of SLP. delivery.
Given the rapid rate at which technology advances, only peer- Standards governing the delivery of SLP services using telehealth
reviewed articles published over the past 5 years (2008–2013) were have not yet been formally established. However, the American
included. Results: The majority of articles reviewed used hybrid Speech-Language-Hearing Association’s Telepractice Working
methodologies to maintain traditional SLP service standards. Gen- Group has published documents providing information and guidance
eral technological components for telehealth activities included for the implementation of telecommunication technology in the field
computers, Web cameras, headsets with an embedded microphone, of SLP.31 The American Telemedicine Association is also a valuable
and Internet connectivity. Conclusions: Advanced technology has resource for ethical, clinical, technical, and administrative standards
limitations in the application of telehealth. Technological adversities with application across telehealth settings.32 Although telehealth can
were not reported as the cause of discontinuation of telehealth be an extension of telemedicine, evidence documenting the efficacy,
services by the practitioner or the individual. Audio and visual cost benefits, and sustainability is needed for development of stan-
disturbances were primarily associated with videoconferencing. dards and widespread adoption. Understanding the new role of
Supplemental asynchronous technology was widely reported as a technology in the diagnosis and treatment of communication dis-
solution to real-time instabilities. orders is vital for the expansion of telehealth as a standard of care.
The purpose of this article is to overview the current technologic
Key words: telehealth, telepractice, telerehabilitation, speech- infrastructure and procedures for telehealth applications in SLP and
language pathology, technology, communication disorders the innate challenges and opportunities.

Introduction Materials and Methods

A
growing body of research advocates the use of tele- A literature search was conducted for telehealth publications
communication technologies to expand speech-language in the field of SLP. Cross-disciplinary search engines, including
pathology (SLP) services,1–28 but only 7% of Americans PubMed, CINAH, ERIC, and PsycINFO, were searched using terms
reported using the Internet for telehealth applications.29 or combination of terms closely related to SLP: ‘‘telespeech,’’

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 KECK AND DOARN

Table 1. Technology Summary

DIAGNOSIS/ WEB HEADPHONES/
REFERENCE PARTICIPANTS DISORDER MODEL DEVICEa VTCb CAMERAc SPEAKERSd MICROPHONEe BANDWIDTH SECURITY
Burns et al.1 n = 18; 42–80 yo Dysphagia and/or S, A A4 B2 C7 D7 E7 1 Mbps No
communication
impairments; head
and neck cancer
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Carey et al.3 n = 3; 13–16 yo Fluency S, A A1P, A1 B1 C1P D1P E1P SLP used cable No
broadband
Internet;
participants
reportedly had
‘‘Internet.’’

Ciccia et al.4 n = 263; speech- Speech, language, S A1 B1 C3 D1 E1 Not specified No

language pathology and hearing
screenings; children screenings
up to 6 yo

Constantinescu n = 61; 52–89 yo Voice disorders due S, A A1 B3 C1 D2 E2 128 Kbps No

et al.5 to Parkinson’s disease

Constantinescu n = 34; 54–85 yo Voice disorders due S, A A1 B3 C1 D2 E2 128 Kbps No

Telemedicine and e-Health 2014.20:653-659.

et al.6 to Parkinson’s disease

Constantinescu n = 1; 65 yo Voice disorder due to S, A A1 B3 C1 D2 E2 128 Kbps No

et al.7 Parkinson’s disease

Goldberg et al.9 n = 2; 41–49 yo Aphasia S, A A1P, A3 B1 C1 D1 E1 Not specified No

1 1 1 1 1
Grogan- n = 38; 4–12 yo Articulation, S A B C D E Educational No
Johnson et al.10 language, and/or network at a
fluency disorder minimum
bandwidth of
10 Mbps

Hill et al.11 n = 24; 16–78 yo Dysarthria S,A A1 B3 C2 D2 E2 128 Kbps Yes

12 1 3 2 2 2
Hill et al. n = 11; 16–78 yo Apraxia of speech S,A A B C D E 128 Kbps Yes

Hill et al.13 n = 32; 21–80 yo Aphasia S,A A1 B3 C2 D2 E2 128 Kbps Yes

14 1 1 1 1 1
Howell et al. n = 3; 63–72 yo Voice disorder due to S,A AP B CP DP EP Broadband Yes
Parkinson’s disease Internet

Lasker et al.15 n = 1; 28 yo Apraxia of speech S,A A1 B1 C1 D2 E2 N/A No

1
Malandraki n = 17; 35–76 yo Dysphagia A A N/A N/A NA N/A Not specified No
et al.16

Malandraki n = 32; 50–75 yo Dysphagia S,A A1 B2 C1 D6 E6 Broadband Yes

et al.17 Internet

Riegler et al.19 n = 12; 20–43 yo Cognitive- S,A A1 B4 N/A N/A N/A Wireless Yes
communication Internet
disorders; mild
traumatic brain injury

Sharma et al.20 n = 10; Simulated dysphagia S,A A1 B3 C5, C6 D5 E4, E5 128 Kbps No
standardized wireless
patients network

Theodoros n = 32; 21–80 yo Aphasia S,A A1 B3 C2 D2 E2 128 Kbps Yes

et al.21

Turkstra et al.22 n = 20; 21–69 yo Cognitive- S A1, A4 B1, B2 C4, C7 D1, D7 E1, E7 512 Kbps and No
communication 900 Kbps
disorders; traumatic
brain injury
continued/

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 TELEHEALTH TECHNOLOGY IN SLP

Table 1. Technology Summary continued

DIAGNOSIS/ WEB HEADPHONES/
REFERENCE PARTICIPANTS DISORDER MODEL DEVICEa VTCb CAMERAc SPEAKERSd MICROPHONEe BANDWIDTH SECURITY
24 4 2 2 7
Ward et al. n = 10; 49–70 yo Dysphagia and/or S A B C D E7 3G phone No
communication network;
impairment; head 3.5 Mbps
and neck cancer
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Ward et al.25 n = 40; 25–94 yo Dysphagia S,A A1 B3 C5, C6 D5 E4, E5 128 Kbps No
wireless
network

Waite et al.26 n = 20; 8–13 yo Childhood literacy S, A A1 B3 C2 D2 E2 128 Kbps Yes

disorders

Waite et al.27 n = 25; 5–9 yo Receptive and S, A A1 B3 C2 D2 E2 128 Kbps Yes

expressive language
disorder

Waite et al.28 n = 20; 4–9 yo Speech disorder S, A A1 B3 C2 D3 E2 128 Kbps Yes

34 1 1 4 4 3
Furr et al. Summative Craniofacial; speech S A B C D E 3-Mbps No
information evaluations and wireless-3G
provided; n = 13; therapy connection or
Telemedicine and e-Health 2014.20:653-659.

4–25 yo standard
cable-Internet

Cherney et al.37 n = 32; 23–76 yo Aphasia S, A A1 B3 C1 D1 E1 Not specified No

a 1
A , personal computer; A1P, participant’s computer; A3, participant’s mobile phone; A4, proprietary.
b 1
B , low-cost software (e.g., Skype); B2, proprietary hardware (e.g., Polycom 7000s); B3, proprietary custom; B4, TeleVyou 500SP videophone (plain old telephone service).
c 1
C , unspecified; C1P, unspecified participant’s Web camera; C2, QuickCam Pro 4000, Logitech; C3, Microsoft Life Cam VX-3000; C4, integrated; C5, fixed sphere camera MP
AF, Logitech; C6, unspecified freestanding; C7, proprietary.
d 1
D , unspecified; D1P, unspecified participant’s headset (headphones with microphone) or speakers; D2, unspecified headset; D3, AHS202i headset, Altec; D4, unspecified
speakers; D5, Duet Executive, Phoenix Web conference speaker; D6, telephone; D7, proprietary; NA, not available.
e 1
E , unspecified; E1P, unspecified participant’s microphone; E2, part of headset; E3, integrated; E4, free-field combined echo canceling; E5, CK55L, AKG lapel microphone;
E6, telephone; E7, proprietary.
A, asynchronous; Kbps, kilobits per second; Mbps, megabits per second; S, synchronous; SLP, speech-language pathologist; VTC, videoconference; yo, years old; Yes,
security features overviewed; No, security features not specified.

‘‘telepractice,’’ ‘‘telehealth,’’ ‘‘telemedicine,’’ ‘‘telerehabilitation,’’ hand-held cameras. General technological components for tele-
‘‘speech therapy,’’ ‘‘speech pathology,’’ ‘‘swallowing,’’ ‘‘speech,’’ and health activities included computers, Web cameras, headsets with an
‘‘language.’’ Given the rapid rate at which technology advances, only embedded microphone, and Internet connectivity. Table 1 gives de- T1
peer-reviewed articles published over the past 5 years (2008–2013) tails. The articles were divided into clinical specialties.
were included. In addition, the articles reviewed used advanced
technologies and contained sufficient information regarding the CHILDHOOD SPEECH AND LANGUAGE DISORDERS
technology used for delivery of SLP services. Historically, school districts have been prone to SLP practitioner
shortages affecting the quality of services, delivery of appropriate
Results services, and workload of school-based SLP practitioners.33 Tele-
The search resulted in 26 peer-reviewed articles. Hybrid methods health offers solutions by enabling remote delivery of services to
were used in the majority (n = 20; 77%) of articles reviewed, whereas underserved schools, professional collaboration, and reduced travel
synchronous accounted for 19% (n = 5), and asynchronous accounted time for SLP practitioners with multiple appointments. A recent
for 4% (n = 1). Depending on the communication disorder and type of survey of school-based SLP practitioners revealed an increase in the
services needed, equipment varied from mobile phones to proprietary use of telepractice from 1% in 2010 to 4% in 2012.33 Telehealth has
systems (e.g., Polycom [San Jose, CA]). Internet connectivity in- been shown to be an effective model for standardized and informal
cluded low bandwidth at 128 kilobits per second (Kbps) to the highest assessments,26–28 screenings,4 and treatment10 of various childhood
reported bandwidth of 10 megabits per second (Mbps), and both low- speech and language disorders.
cost and custom videoconference software has been used. Use of A pilot study, conducted in a rural Ohio school district, provided
peripheral devices ranged from external headsets to high-quality articulation and language treatment using PC-based videoconferencing

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transmitted over a 10-Mbps Internet connection to students with clinical trial, researchers at the Australian Stuttering Research Centre
communication disorders. Visual materials were displayed by the SLP at the University of Sydney demonstrated the viability of combining
practitioner using a document camera, and headsets were given to the Internet videoconferencing and asynchronous technology to deliver
students. Trained facilitators provided tech support, maintained atten- the Camperdown Program to adolescents who stutter.3 Treatment was
dance logs, communicated with the remote SLP practitioner, and dis- delivered via Skype and recorded by the SLP practitioner using Pa-
seminated and collected therapy materials from the child.10 Urban mela, a Skype add-on. Home practice speech samples were recorded
community-based clinics in Ohio conducted speech and language using the audio editor Audacity (developed at Carnegie Mellon
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screenings focused on articulation, receptive and expressive language, University, Pittsburgh, PA) and e-mailed to the SLP practitioner.
and play/social behavior over Skype (Luxembourg) videoconference
software using similar basic technology, a laptop computer, and a Web VOICE DISORDERS
camera.4 To date, work in telehealth and voice has pertained to individuals
In a series of studies conducted at the University of Queensland, with voice disorders due to Parkinson’s disease. Diagnosis and man-
Brisbane, Australia, researchers used a PC-based system with custom- agement of voice disorders via telehealth present unique technological
ized software to demonstrate the potential of telehealth for standardized challenges. Analysis of voice relies on perceptual judgments, objective
assessment of literacy skills,26 receptive and expressive language,27 and acoustic and aerodynamic measurements, and, laryngeal imaging. In
screening of speech intelligibility and oral motor structure and func- order for services to be completely remote, technology must be capable
tion.28 The PC-based system allowed SLP practitioners to videoconfer- of transmitting voice signals over the Internet without compromising
ence, over a 128-Kbps Internet connection, with children who were their acoustic integrity. This is important for acoustic and perceptual
Telemedicine and e-Health 2014.20:653-659.

equipped with headphones and microphones. Web cameras, mounted analysis. Efficacious analysis via telehealth has required synchronous
on a motorized base above the child’s monitor, were controlled by the methods to be supplemented with FTF services,14 asynchronous tech-
online SLP practitioner and enabled the professional to concurrently nology,5–7,14 and/or advanced software.5–7
view the child and video-record the assessment.26–28 The SLP practi- A pilot study conducted by researchers in the United Kingdom
tioner monitored the child and electronic stimulus materials simulta- showed the feasibility of using Skype videoconferencing to deliver
neously on two monitors. Electronic stimulus files were displayed by the the Lee Silverman Voice Treatment (LSVT) to participants with
SLP practitioner and included prerecorded audio, video, text files, and voice disorders due to Parkinson’s disease.14 Web-based sessions
scanned images of text files. Verbal responses were captured via the were conducted using broadband Internet videoconference and the
headset microphone, and all audio recordings were automatically stored participant’s home PC, Web camera, and headset with microphone.
on the child’s computer first and then forwarded to the SLP practi- Supplementing the videoconference sessions was a weekly FTF ses-
tioner.26–28 Lastly, a capacitive touch screen displayed the child’s touch sion conducted in the participant’s home to objectively measure
responses on the SLP practitioner’s monitor and then stored and for- sound pressure (loudness), establish a therapeutic relationship, and
warded the data to the professional’s computer.26,27 to review home practice materials.14 Recordings collected during FTF
and Skype sessions, using HotRecorder (www.hotrecorder.com),
CRANIOFACIAL were forwarded to participants using e-mail for guided practice.
Multidisciplinary postoperative care for individuals with cleft lip/ A custom PC-based telehealth system developed at the University of
palate is critical, and for people in developing countries, access to Queensland achieved remote standardized and informal assessment5
these services is limited. Telehealth, however, has the potential to and treatment6,7 of speech and voice disorders associated with Parkin-
bridge the distance between trained specialists in developed countries son’s disease. The PC-based telehealth equipment and software cap-
and individuals in remote regions. Multidisciplinary teams in the abilities used in the voice literature5–7 were similar with those used for
United States have recently explored the potential of telehealth to studies of childhood speech and language disorders.26–28 Customized
provide pre- and postoperative speech evaluations and speech ther- software supported videoconferencing (320 · 240 pixel resolution),5,7
apy internationally to individuals with cleft lip/palate.34 Summations electronic data sharing, and the SLP practitioner’s remote control of the
of their experiences describe the use of low-cost videoconferencing Web camera. Additional features enabling remote delivery of services
(iChat; Apple, Cupertino, CA) over high-speed (3 Mbps) wireless-3G for voice disorders included (a) the ability to capture high-quality video
or standard commercial cable-Internet and off-the-shelf technology, (640 · 480 pixel resolution)5–7 and audio recordings (384 Kbps)5–7 sep-
computers equipped with Web browsing software, audio speakers, an arate from videoconferencing, (b) review of synchronous files as needed,
integrated Webcam, and a microphone, as essential equipment.34 and (c) viewable samples of real-time calibrated average measures of
Real-time sessions were supported by facilitators at the remote sites loudness, pitch, and duration data via an acoustic speech processor.
who assisted with administrative and technical support. Participants were not required to interact with the software as all fea-
tures were either automatic or SLP practitioner directed.5,7
FLUENCY
The use of low-tech telehealth technology such as plain old tele- NEUROGENIC COMMUNICATION DISORDERS
phone service and postal service mail, has previously been used to Neurogenic communication disorders are the result of brain insult
deliver fluency interventions to adults and children.35,36 In a Phase I or disease processes and can affect language (aphasia) understanding

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 TELEHEALTH TECHNOLOGY IN SLP

and formation, speech production (dysarthria and apraxia), and bers or caregivers underwent training to provide technology support
cognitive functions. Differential diagnosis of neurogenic communi- for participants.
cation disorders is crucial for appropriate management; therefore,
telehealth methods have incorporated flexibility and usability of DYSPHAGIA
technology. Valid and reliable standardized and informal assessment Swallowing difficulties (dysphagia) can cause serious health
of dysarthria,11 aphasia,13,21 and apraxia of speech12 were demon- complications such as malnutrition, aspiration, and potentially
strated using a custom PC-based telehealth system developed at the death.38 SLP practitioners’ interventions have been shown to improve
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University of Queensland.5–7,26–28 The system’s software enabled swallowing safety, thus reducing the length of hospital stays and
videoconferencing over 128 Kbps supplemented with asynchronous decreasing expenses related to pneumonia and other pulmonary
audio and video.11–13,21 Electronic data sharing permitted display of complications.38 Dysphagia assessments can use both instrumental
instructional images and video clips11–13,21 and touch responses.12,13,21 and clinical examination. Concurrent with FTF standards, remote
The SLP practitioner controlled recording of high-resolution high- assessment requires evaluation of oral and laryngeal structure/
quality video footage and audio files independent of the video- function and trials with varying consistencies of food and liquid. The
conference, as well as remote camera positioning. Participants were current telehealth infrastructure limits the type of procedures that
not required to interact with the software.11–13,21 can be accomplished remotely; therefore, studies have investigated
Less sophisticated technology was shown to be effective for as- balancing technology with facilitators.20,25
sessment of discourse ability in adults with posttraumatic brain Limited availability of adequately trained SLP practitioners in
injury.22 Although equipment and connectivity varied between two instrumental swallowing assessments is a global concern. Real-time
Telemedicine and e-Health 2014.20:653-659.

settings (Table 1), assessments were conducted using videoconfer- transmission of videofluoroscopic swallowing studies (VFSS) was
encing software (i.e., iChat) and hardware (e.g., Polycom 7000s) over achieved using PC-based videoconference hardware over broadband
high-speed Internet (512 Kbps or maximum of 900 Kbps) connec- Internet.17,18 Communication between the fluoroscopy suite and the
tivity. Videoconferencing occurred over both platform-specific remote SLP practitioner was conducted using a speaker telephone.
equipment and computers. No differences in video or audio quality Store-and-forward technology enabled repeated viewing of the VFSS
or transmission speed between the two settings’ telehealth systems images and was controlled by the remote SLP practitioner.17,18 In an
were reported.22 A facilitator was present with the participants to international pilot study, VFSS were performed and recorded by less
monitor safety and equipment, in addition to assisting with task experienced practitioners in Athens, Greece and then uploaded to a
materials. Web site for an expert SLP practitioner’s consultation at Columbia
Telehealth has also enabled efficient,19 intensive,9,15,37 and indi- University in the United States. A virtually lossless compression
vidualized9,15,37 management of neurogenic communication disor- codec was used to maintain video fidelity. The expert SLP practi-
ders. A case study examined the use of Skype to deliver a portion of tioner retrieved the information via the Web site 1 day after the
SLP services to an adult with severe apraxia of speech.15 Video- evaluation was conducted in Greece.16
conferencing was conducted using PCs, headsets, and recorded using Clinical swallowing evaluations were effectively administered using
Call Recorder software (www.ecamm.com/mac/callrecorder/). Re- a custom videoconferencing system with facilitator assistance.20,25 The
cordings were used to assess progress, and telehealth was supple- telehealth system was composed of two notebook computers equipped
mented with FTF sessions. Similarly, researchers at the University of with custom videoconferencing software using high-quality audio and
North Carolina at Chapel Hill have demonstrated the feasibility of video compression technology over a 128-Kbps bandwidth and store-
using Skype videoconferencing for a portion of therapy sessions and-forward technology.20,25 The participant’s system was portable
aimed to deliver a modified script training intervention to adults with and required no technological interaction. Web cameras allowed
aphasia. This study also used asynchronous independent home concurrent visualization of the participant and the SLP practitioner.
practice using the participant’s PC or mobile phone.9 The participant’s Web camera was freestanding on an adjustable
Soldiers with mild traumatic brain injury who were previously mobile platform and enabled remote control and zoom by the SLP
noncompliant with traditional therapy were shown to be adherent to practitioner. Split-screen imaging allowed concurrent viewing of the
cognitive rehabilitation therapy using videophone (used plain old participant and SLP practitioner. Communication occurred through a
telephone service) intervention combined with self-guided Web- free-field combined echo-cancelling microphone and Web conference
based learning modules.19 Modules were accessed via computer and speaker.20,25 The participant’s voice quality was captured and recorded
included didactic video clips, cognitive strategies, and homework. using a lapel microphone. A finger pulse oximeter was used to measure
People with aphasia used virtual therapist software to complete a the participant’s oxygen saturation throughout the assessment. The
structured language intervention in their home setting both asyn- facilitator’s role was to perform tasks under the SLP practitioner’s
chronously and synchronously when an SLP practitioner monitored direction, to evaluate and relay haptic and/or missed information to
in real-time.37 The virtual software was accessed via the SLP prac- the SLP professional, and to adjust the equipment as necessary.20,25
titioner’s and participant’s computers through the Internet. Software Similar technology was used for swallowing and communication
features included the option of real-time communication, customi- evaluations with head and neck cancer1 and post-laryngectomy24
zation, and store-and-forward progress monitoring.37 Family mem- patients. Mobile telehealth systems enabled videoconferencing over a

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3.5-Mbps 3G wireless phone network24 and 1 Mbps.1 External cameras has been demonstrated.1–28 SLP practitioners engaged in telehealth
captured high-quality video and still images. Hand-held medical activities are responsible for providing the same quality of services
cameras (Flexi dock 200; Inline Medical and Dental Pty., Sydney, via telehealth as they would be FTF.31 The infrastructure of telehealth
Australia) with general imaging and intraoral probes were also used for is a significant component of telehealth models of delivery. There-
close examination of the stoma and oral cavity.1 Split-screen imaging fore, it is essential that SLP practitioners be educated on the suc-
allowed simultaneous viewing of the participant and the SLP practi- cessful implementation of technology, challenges that have been
tioner.1,24 Additional lighting sources enhanced visualization of ex- encountered, and future applications.
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amined structures.1,24 The technology was either remotely controlled

or operated by the SLP practitioner.1,24 Store-and-forward technology Acknowledgments
enabled consultation with specialists.1 The authors would like to thank Dr. Lisa Kelchner and Dr. Nancy
Creaghead for their assistance and support.
Discussion
TECHNOLOGY CHALLENGES Disclosure Statement
Advanced technology has limitations in the application of tele- No competing financial interests exist.
health. Mashima and Doarn39 highlighted the importance of selecting
connectivity mediums, bandwidth, and equipment based on desired
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