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Online Audiologic RehabilitationPerry C. Hanavan. MA, FAAA

Augustana College

Sioux Falls, SD

ARA Summer Institute 2001

Vancouver, BC

June 7-10, 2001

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AfricaEvery morning in Africa, a gazelle wakes up.

It knows that it must run faster than the fastest lion,

Or it will be killed.

Every morning in Africa, a lion wakes up,

It knows that it must outrun the slowest gazelle,

Or it will starve to death.

It doesn’t matter whether you’re a lion or a gazelle,

When the Sun comes up in the morning, you’d better be running.

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Samburu Warrior

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Appointments

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Internet Growth

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Found in ESG Message

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Village ….?

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Traditional AR

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21st Century AR

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Not Without Problems

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Experimental System

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Web for AR

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World E-Commerce and Internet Market Report

Top five countries in each new-economy indicator category:• Financial transactions - Amount of credit cards issued per person, per year

and credit card spending -- Iceland, Luxembourg, U.K., US and Canada.

• Literacy and education rates - Ability to meet the educational needs of a competitive economy -- Finland, Australia, Canada, Iceland and the US.

• Market potential - Measures standard of living and retail sales -- US, Finland, Iceland, Canada and Taiwan.

• Globalization - Willingness to accept foreign economic influence and embrace the global capital market -- Netherlands, Hong Kong, Finland, Ireland and Sweden.

• Technological sophistication -- Number of computers and Internet connections — US, Finland, Iceland, Canada and Taiwan.

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What is the Internet

"The Internet isn't about wires and tubes. In effect, it's about change. A whole host of things in our world are just waiting to be changed, longing for better solutions, and the Internet is the stimulus, and perhaps the means, to unleashing these pent-up desires, trends, and forces to their next natural state.”

Weintaub, JN. (1997) Capital thoughts. Internet World, March

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They’re Here!

• “As audiologists we need to adjust our model…The internet is the tool not the solution that will pave the way for the new model.” (Glen Meier)

Northern, JL. (2001) Hearing services on the internet: They’re here! Audiology Today. 13(2):7.

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Old Technology

It’s not how hard you work…

It’s how much work you get done.

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Why Consider Online AR?• Online AR information is apart of the global resources

that constitute the Internet• Online AR information is easily accessed

– Search engines (Google, AltaVista, HotBot)– Directory services (Yahoo) (SearchWave)– Professionals, organizations, business, government,

laypersons have created resources

• Consumers, professionals, and others want access to online AR information

• Improve audiologist-patient relationships

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High Tech High Touch ServiceHealthcare consumers experiences before, during or after visits to their physicians:

• forgetting to ask all their questions during doctor visit (60%),

• having to see doctor in person to ask questions that could be answered by telephone or e-mail (41%),

• getting through to someone who could answer questions (35%),

• providing the same information over and over again each visit to doctor’s office (35%),

• not having enough time with doctor (29%).

http://www.harrisinteractive.com/about/healthnews/HI_HealthCareNews-V1-Issue1.pdf

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High Tech High Touch

• Online population would like to receive e-mail reminders for preventive care (81%),

• Follow-up e-mails after visits to doctors (83%)

• For their doctors to be able to access and monitor their lab tests online (84%).

http://www.harrisinteractive.com/about/healthnews/HI_HealthCareNews-V1-Issue1.pdf

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Time Spent by ProfessionalsAverage Amount of Time Professionals Spend Explaining Details of

Hearing Test Results----------------------------------------------------------------------------------Topic Oto Aud----------------------------------------------------------------------------------Shortest time in minutes (mean) 5.86 5.94

Range .25-30 0-30

Average (minutes) 11.95 12.41Range 2-60 2-75

Longest time in minutes (mean) 25.72 26.94Range 3-120 4-120

Martin, FN, Bar, MM, and Bernstein, M. (1992). Professional attitudes regarding counseling of hearing-impaired adults. American Journal of Otolaryngology. 13(3): 979-287.

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Time Spent by ProfessionalsAverage Amount of Time Professionals Spend Explaining

Implications of the Hearing Impairment----------------------------------------------------------------------------------Topic Oto Aud----------------------------------------------------------------------------------Shortest time in minutes (mean) 6.91 6.81

Range 0-7.4 0-30Average (minutes) 13.57 13.89

Range 1-300 2-75Longest time in minutes (mean) 31.32 32.55

Range 2-600 4-240

Martin, FN, Bar, MM, and Bernstein, M. (1992). Professional attitudes regarding counseling of hearing-impaired adults. American Journal of Otolaryngology. 13(3): 979-287.

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Internet Applications of AR

• E-mail

• Electronic Support Groups– Discussion groups– Listservs– Forums– Chats

• World Wide Web

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E-mail and AR

• Person to person communication

• TeleAR– Video clip attachments– Digital photo attachments– Document (forms) attachment

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Electronic Support Groups

• Professional to consumer

• Consumer to consumer

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WWW• Text

• Graphics

• Videos

• Simulations

• Virtual reality

• Forms

• Interactive programs

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Online AR• Patient diaries• Educational information• FAQs• Electronic support groups• Forms• Scheduling information• Maps (directions)• Resources

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Profusion of Web Content

• Information is only as useful when relevant to problem, valid, and easy to access

• Slawson formula:

Usefulness=relevance x validity/work to access

Slawson, DC, Shaughnessy, AF, and Bennet, JH. (1994). Becoming a medical information master: feeling good about not knowing everything. Journal of Family Practice. 38:505-13

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Telemedicine applications

• Video-otoscopy captures the image • The use of live video teleconferencing to

evaluate and treat patients in-house preliminary results show no difference in outcomes

Burgess LP, Holtel MR, Syms MJ, Birkmire-Peters DP, Peters LJ, Mashima PA. (1999) Overview of telemedicine applications for otolaryngology. Laryngoscope. 109(9):1433-7

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Email and AR

Last accessed

June 4, 2001

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Email and AR

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Email and AR

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Email and AR

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Email and AR

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Electronic Mail• 70 inquiries from published

web site– 39 patient inquiries– 20 family inquiries– 11 unknown relationship

• 1.3 (avg) inquires per week• 2 (avg) messages to follow-up

(range 1-10)• 2 (avg) number of replies

(range 1-9)

Widman, LE and Tong, DA. (1997) Request for medical advice from patients and families to health care providers who publish on the world wide web. Archives of Internal Medicine. 157:209-212.

• 96% – identified qualified consultant in area of cardiology

• 74% - identified the author’s expertise of arrhythmias

• 70% sought a second opinion• 21% sought advice whether to

consult a physician

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Electronic Mail• 44 - diagnosis and management

of cardiac arrhythmias

• 8 - recording procedures

• 5 - diagnosis and management of coronary artery disease

• 10 - other areas of clinical cardiology

• 2 - general internal medicine

• 1 - neurology

Widman, LE and Tong, DA. (1997) Request for medical advice from patients and families to health care providers who publish on the world wide web. Archives of Internal Medicine. 157.209-212.

• 15 - help in establishing a diagnosis

• 14 - select or understand therapy for established diagnosis

• 1 - understand prognosis

• 6 - obtain information about a disease or medication

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Electronic Mail

• Conclusions:– Individuals can identify qualified consultants

outside local health care system and communicate directly with provider

Widman, LE and Tong, DA. (1997) Request for medical advice from patients and families to health care providers who publish on the world wide web. Archives of Internal Medicine. 157:209-212.

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Why Email and AR?

• Public is well-educated, curious, and used to seeking health care from printed media

• HMO’s have financial disincentives to provide needed treatments, lack referrals to specialists, etc.

• Traditional insurance plans may not pay for or pay only a portion of services, therefore, patients are verifying necessity of proposed evaluations

• Lack of resources in rural or remote areas, globally

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Electronic Mail• Ethical issues – duty to respond, increasing growth of Internet users• Compensatory issues – overhead, academic credit, professional

societies• Legal issues – no legal responsibility to respond, disclaimer, saved

as medical record, state and foreign country laws• Confidentiality issues – non-encrypted records, printed and saved

as medical record, not released to others without consent• Information Quality issues – expert source, educate layperson

about information quality on the Internet

D’Alessandro, DM, D’Alessandro, MP, Colbert SI. (2000) A proposed solution for addressing the challenge of patient cries for help through an analysis of unsolicited electronic mail. Pediatrics. 105(6): http://www.pediatrics.org/cgi/reprint/105/6/e74.pdf

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E-mail from VT of the Ear

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Electronic Support GroupsSix-level system in information-age health care, patient-consumers may seek what they need in the following order:

• individual self-care, • family and friends, • informal self-help networks, • the professional as coach, • the professional as partner, • professional as authority.

Ferguson T. (1997) Health online and the empowered medical consumer. Jt Comm J Qual Improv 23(5):251-7

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Electronic Support Groups

Benefits:• getting information,

• sharing experiences, receiving general support,

• venting feelings,

• gaining accessibility,

• using writing.

Disadvantages:• "noise,"

• negative emotions,

• large volume of mail,

• lack of physical contact and proximity.

Han, HR and Belcher, AE. (2001) Computer-mediated support group use among parents of children with cancer--an exploratory study. Computers in Nursing 19(1):27-33.

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Electronic Support Groups

Impact of Internet use on coping ability of HIV patients found three themes:

• Internet promotes empowerment, • augments social support, • facilitates helping others

Reeves, PM. (2000) Coping in cyberspace: the impact of Internet use on the ability of HIV-positive individuals to deal with their illness. J Health Commun. 5 Suppl:47-59

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ESG – CF Teens• Teenagers with chronic disease will actively participate in ESG• ESG helped meet psychosocial needs• Management of ESG was extremely easy• ESG utilized inexpensive technology• Patients who are difficult to assemble in one physical location

may benefit from participating in an electronic support group (ESG).

Johnson KB, Ravert RD, Everton AE. (2001). Hopkins teen central: Assessment of an internet-based support system for children with cystic fibrosis. Pediatrics. 107(2): E24 http://www.pediatrics.org/cgi/reprint/107/2/e24.pdf

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ESG - CF

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ESG – HH/D Teens

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Electronic vs Traditional SG• Traditional Support Group Barriers:

– Practical -- travel, transportation, schedules– Medical -- health factors, weakness– Stylistic -- incongruent attitudes

• Electronic Support Group Barriers:– Computer with Internet connection– Computer skills– Visual acuity and finger dexterity– Lack of non-verbal communication

Weinberg, N Schmale, J, Uken, J, Wessel, K. (1995) Computer- mediated support groups: Social work with groups. Social Work with Groups. 17(4):43-45.

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Electronic Support Groups

• http://groups.yahoo.com

• http://groups.google.com/ (fomerly www.deja.com)

• http://www.topica.com/

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CI Electronic Support Groups• forum@nucleusci.com• http://groups.yahoo.com/group/ci• http://groups.yahoo.com/group/cifamily• http://groups.yahoo.com/group/CI-Prelinguals• http://groups.yahoo.com/group/citeens-preteens• http://groups.yahoo.com/group/ProblemCI• listserv@yorku.ca • http://www.delphi.com/parentsclarion/start/• http://www.topica.com/lists/cochlearimplants/

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Specialty Electronic Support Groups

• http://groups.yahoo.com/group/AuditoryNeuropathy• http://www.topica.com/lists/menicircle/

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HOH Electronic Support Groups• http://groups.yahoo.com/group/HOH-LD-News/

• http://groups.yahoo.com/group/LDAchat/join

• http://groups.yahoo.com/group/Hearing_Aids

• http://groups.yahoo.com/group/Listen-Up

• http://groups.yahoo.com/group/USA-L_News

• http://groups.yahoo.com/group/hear

• http://groups.yahoo.com/group/bhNEWS

• http://www.hearinglossweb.com/

• alt.support.hearing-loss (groups.google.com)

• majordomo@duke.edu subscribe beyond-hearing

• The Hard of Hearing / Deafened Live Forum (AOL)

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Web Content• assessed quality of information a lay person could obtain from

Internet sources regarding the treatment of childhood diarrhea

• low percentage of concurrence with the AAP guidelines

• medical institutions, schools, and hospitals need to devise ways to carefully monitor and establish quality control of what is being distributed from their home pages

• patients must be warned about the voluminous misinformation available on medical subjects on the Net

McClung, HJ, Murray, RD, and Heitlinger, LA. (1998). The internet as a source of current patient information. Pediatrics. 101(6): http://www.pediatrics.org/cgi/reprint/101/6/e2.pdf

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Therapy and WWW

• WWW resources, structured behavior components, weekly contact, individualized therapist feedback delivered via e-mail (best)

• WWW resources alone (produced results)• Conclusions: Internet appears to be a viable

method for delivery of structured program

Tate, DF, Wing, RR and Winett, RA. (2001) Using internet technology to deliver a behavioral weight loss program. JAMA. 285(9):1172-1177.

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WWW and ESG• New mode of communication that will play vital role for

nurses• Site helps users learn about their disease and become

active in their own management• Site provides nurses with a means to teach patients in a

supportive environment• Site serves as patient advocate• Potential to contribute to the development of a new

nursing knowledge base in the form of nursing informatics

Bliss, J, Allibone, C, Bontempo, B, Flynn, T and Valvono. NE. Creating a Web site for on-line social support melanocyte. Computers in Nursing. 16(4):203-207.

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WWW for Med Information• 924 gastroenterology patients surveyed• 50% reported access to Web• 51% of those with access had searched the web for

medical information• 60% of surveyed intended to use web for

searching medical information• 4% (35) had ever been referred to the Web by

their physician

O’Connor, JB and Johanson, JF. (2000). Use of the web for medical information by gastroenterology clinic population. JAMA.284:1962-1964.

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Web and Consumer Voice• Compared professional, commercial and consumer generated

Web sites• 53 different treatment types were mentioned• Antidepressant medication and psychotherapy were noted by

almost all sites• Consumer sites mentioned psychological therapies less

frequently• Consumer sites provide a voice to inform psychiatrists and

GPs about preferred treatments and side effects

Christensen, H, Griffiths, KM and Medway J. (2000). Sites for depression on the web: a comparison of consumer, professional and commercial sites. Aust N Z J Public Health. 24(4):396-400.

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JIT, Web, and Healthcare

• Provided educational information via the Web to reduce postoperative pain following surgery

• Patients who had access to the pain management information on the Web site reported significantly less postoperative on arrival to their home after surgery

• Concluded that using the Internet to provide just in time patient education can significantly effect the clinical outcome of care

Goldsmith, DM and Safran, C. (1999). Using the web to reduce postoperative pain following ambulatory surgery. Proc AMIA Symp:780-784.

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Web Based AR

• John Tracy Clinic (online correspondence)

• hear-it.org – (youth, medical, adult, political versions- IFHOH)

• HearingAidHelp.com (Hearing Planet)

• www.hearing411.com (Siemens)

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Web Based Evaluations

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AR and the Web

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Professional.orgs and the WWW

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Professional.orgs and the WWW

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Professional.orgs and the WWW

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Combining Efforts of Orgs

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From Russia with Love

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From Russia with Love

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From Russia with Love

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HA Manufacturers and the Web

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HA Manufacturers and the Web

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Audiologists and the Web

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Government/Health/Web

Stephenson, J. (2000) National library of medicine to help consumers use online health data. JAMA. 283(13):1675-1676.

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Government/Health/Web

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Medline/PubMed

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Web Resellers

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E-Manuals

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Orgs and the Web

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World Orgs

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Assessment on the WWW

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Internet and Telemedicine

Gray, JE., et al. (2000) Baby CareLink: Using the internet and telemedicine to improve care for high-risk infants. Pediatrics. 106(6):1318-1324.

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Reimbursement

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Reimbursement

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Assessing WWW Quality

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Guidelines for AMA Web Sites

• Principles for content

• Principles for advertising and sponsorship

• Principles for privacy and confidentiality

• Principles for e-commerce

Winker, MA, et al. (2000) Guidelines for medical and health information sites on the internet: principles governing AMA web sites. JAMA. 283(12):1600-1606).

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Conclusion• Online healthcare is having a growing cultural impact• Effecting the image of the practitioner-patient relationship• Consumers are bringing new strategies into their acquisition of

health information and care• Professions are attempting to establish norms for “proper use”

of the Internet for consumers• Healthcare communities should establish approaches that

empower consumers to use Internet as part of healthcare (AR) strategy

• Statuses of professionals may be bolstered as they develop ways to empower and support consumers use of the Internet

Oravec, JA. (2001). On the “proper use” of the internet: self-help medical information and on-line health care. J Health Soc Policy. 14(1):37-60.