Review of the Current Evidence of Remote Service Delivery in the Field of AAC

Literature review

Review of the current evidence of remote service delivery in the field of AAC

Background

The Department for Education project looked at Augmentative and Alternative Communication (AAC) services throughout England and set a back drop for this review. The aim of the project was to assist in the transition to a new model of service delivery. As part of the project, the feasibility of using technology to deliver AAC services remotely was explored.

As telecommunication and information technology has advanced, so too has the promise of utilising these technologies to deliver health and social care services remotely. The terms telemedicine, telehealth and others are used to describe the broad definition of using technology to provide services remotely. Initially this was largely viewed as a tool for providing services for those in remote locations. As the field has evolved, focused areas have developed which incorporated its use into existing service delivery models. One such example is telerehabilitation (telerehab), using technology to deliver traditional rehabilitation services. (Theodorus D, 2008)

The driving force behind the adoption of telerehabilitation services are generally related to the perceived benefits telerehabilitation can provide to patients, service providers and the health care sector as a whole. (Hill, et al., 2008) The development of an alternative method to face-to-face treatment that is accessible, flexible, and equally therapeutic and cost effective has the potential to enhance the rehabilitation process.

Services within the NHS, social care and education are being encouraged to take advantage of the benefits remote care can offer.

There is a growing amount of literature on the use of telemedicine and telerehab technology for remote assessment and intervention in rehabilitation (Lemaire, Boudrias, & Greene, 2001; Torsney, 2003; Winters, 2002). The concept of delivering remote AAC services using telerehab tools and techniques is emerging.

Systematic reviews enable the current body of literature to be summarised and critically analysed which can provide a useful tool for clinical judgments and service planning. The use of telerehab technology in AAC service delivery is increasing and there is a growing body of literature on AAC service related activities, however there are no systematic reviews in this area. This review will explore the literature to evaluate the use of telerehab for activities involved in AAC service delivery.

Search strategy

To explore the current state of research in remote service delivery in AAC a search was conducted through Medline (PubMed) database, Google Scholar and NHS Evidence. The literature search was divided into two categories by the type of technology used to deliver remote services, namely Video Conferencing and remote access of electronic devices used in AAC services. An initial search strategy used keywords to query the databases, this resulted in a large number of papers retrieved. The scope and time restrictions on this review required a more precise search strategy. A PICO (Population, Intervention, Comparison, Outcome) search strategy was employed for both video conferencing and remote access to refine the search into an evidenced based query.

1Video Conferencing

The following statement and subsequent key words were searched in accordance with the PICO search strategy.

The following search question was posed:

“Has video conferencing been used as an alternative to face to face methods for delivering AAC services?”

Population / Intervention / Comparison / Outcome
AAC Services / Video Conferencing / Face to face / Feasible
Speech and language services / Telehealth / Conventional service delivery / Effective
Assistive technology services / Telemedicine / Useful
AAC users / Telecommunication / Practical
Telerehab
Telerehabilitation

Table 1: Video Conferencing PICO search strategy key word synonyms.

The search resulted in 20 published papers with research most widely studied in North America followed by Australia and Europe. Grey literature was excluded from the search. The majority of the literature focused on areas of cost effectiveness, feasibility or acceptability.

The literature revealed a variety of technologies used across the studies. Over this time technology has changed and evolved. Broadly there are two categories of video conferencing delivery:

• Synchronus – often referred to as “real time” delivery used for capturing, transmitting, receiving, and presenting of video, audio and other data in real time of delivery. The majority of studies have used synchronous video conferencing delivery. (Brennan, et al., 2002) (Georgeadis, et al., 2010) (Brennan, 2004) (Theodorus D, 2008) (Styles, 2008) (Theodorus, 2008) (McCullough, 2001) (Hill, et al., 2008) (Kully, 2000)
• Asynchronus – relates to the storing and forwarding of recorded data. i.e. data collected and viewed is not in real time. This method of service delivery is often used to supplement current models and provide an opportunity for review and validation. (O'Brian, et al., 2008) (Theodoros, et al., 2006)

1.1Benefits of Video Conferencing

The benefits of telerehab are both application and context dependent, in this case the following potential benefits relate specifically to activities carried out by AAC services using video conferencing.

1.2Barriers and Limitations

The potential benefits highlight the vast potential for future development of video conferencing in this field, However there are a number of barriers and issues that were identified and need to be addressed to ensure these potential benefits can be realised and evaluated effectively. The obstacles range in breadth and difficulty.

1.2.1Clinical efficacy

1.2.1.1Patient and Session Selection

The majority of research studies feature non randomised studies with participants often identified on a case by case basis, acknowledging that video conferencing may not be appropriate in all circumstances or for all clients. Studies by Brennan, Georgeadis et al, recognise a number of factors influencing candidacy of clients for video conferencing. Behavioural, physical, sensory and cognitive ability may adversely affect a client’s ability to interact using video conferencing equipment. Several studies have focused on the use of video conferencing with adult clients with acquired neurological disorders such as stroke and Parkinson’s disease. There have been fewer studies with children and those with conditions from birth or early childhood. Georgardis et al recognise that the positive results found with participants involved in story re-telling by adults with neurogenic communication disorders cannot be applied to those with severe cognitive communicative impairment, dysarthria or aphasia. (Georgeadis, et al., 2010). It is widely established in the literature that selection of clients is a critical factor in successful outcomes and requires careful thought by healthcare professionals.

A study by Brennan reported that age, education, experience with technology and gender did not significantly impact inter participant performance of brain injured patients. (Brennan, 2004)

Early studies such as that by Duffy et al identified challenges healthcare services face in delivering certain activities remotely. (Duffy, et al., 1997) The inability to physically manipulate and assess muscle strength and musculoskeletal tension could omit important information and impact the clinical effectiveness of the session. One important criterion for evaluating the effectiveness of videoconferencing is the extent to which decisions and opinions made face-to-face and via videoconferencing are concordant. The studies highlighted the lack of robust evidence in support of this, more robust randomised controlled trials would prove beneficial.

1.2.2Technology

Video conferencing hardware, software and peripheral devices will continue to evolve and change as they incorporate wider advances in technology. This is reflected in the range of technology used across the studies at the time they were undertaken. The functionality and quality of audio and video data is determined by the system used to deliver video conferencing i.e. hardware, software and peripherals and the infrastructure or network across which they connect.

The studies used a range of hardware and software technology ranging from dedicated video conferencing systems such as Polycom through to the use of standard computers with a standard web cam and headset with the use of freeware such as Skype. Few studies addressed the prior need to select appropriate technology; studies were often limited to current resources and availability. Georgeadis recognised the need to ensure consistent audio quality to improve user acceptance. (Georgeadis, et al., 2010). Selection of appropriate videoconferencing equipment involves consideration of camera capabilities (e.g., pan-tilt-zoom [PTZ] and resolution), display monitor capabilities (e.g., size, resolution, and dual display), microphone and speaker quality. Technology used for AAC services should not distort or interfere with communication as the quality of the data must support clients with communication disorders. (Brennan, 2004)

Studies by Theodoros, Georgeadis and Styles reported network difficulties resulting in audio delays and poor video quality and pixilation. (Theodoros, et al., 2006) (Georgeadis, et al., 2010) (Styles, 2008)

Network difficulties are often as a result of bandwidth limitations, bandwidth describes the amount of data that can be carried from one point to another in a given time period. Jarvis-Selinger et al recommended that a minimum bandwidth of 384 Kbps was needed in most applications to establish adequate audio and visual clarity. However as hardware and software capabilities change so do the demands on the bandwidth, features such as high definition cameras, multi-point conferencing and additional functionality such as screen and document sharing are all placing increased demands on the amount and speed of data needing to be transferred. Available bandwidth may also be reduced by the number of users on the communication network at any point in time. Adequate, consistent and reliable bandwidth is crucial for limiting technical difficulties during sessions and therefore limiting some resultant outcomes of this.

The quality of video and audio data impacts the accuracy or remote assessment. (Durfee, et al., 2007). This can also impact user and professional acceptance and satisfaction. (Styles, 2008)

All of the studies identified took place under controlled conditions with controlled environments and technical support. It is therefore difficult to quantify the significance of technology barriers in the overall effectiveness of a video conference session. For example lack of technological compatibility may be a barrier to connecting sites with different hardware, software, and bandwidth speeds.

1.2.3Client Acceptance and Satisfaction

In addition to positive clinical outcomes, video conferencing applications have yielded favourable client feedback. With technological advancements and ubiquitous use of computers and desktop video conferencing solutions in daily life, service delivery with this method can be desirable particularly for patients with an interest in technology. (Mashima & Doarn, 2008) Duffy et al highlighted the support some clients may require to use a new method for service delivery. In this study with support of an on-site healthcare professional for the client they were able to more effective participation in the session (Duffy, et al., 1997). However the need for onsite assistance may negate some of the potential cost saving benefits of video conferencing.

In Brennan et al’s study, 4 out of 10 patients with left and right CVA reported that their comfort level was better in the video conferencing session because they felt “less self conscious” or were less distracted because “the computer made it interesting”.

1.2.3.1Professional Acceptance and Satisfaction

Theordoras and Russell discussed the scepticism of professionals about the ability to perform remote assessments. This is primarily due to a lack of exposure to telerehabilitation technologies and the limited number of published diagnostic equivalence studies. Similarly, many practitioners have great difficulty in conceptualising how to apply traditional ‘hands on’ therapy remotely through video conferencing. (Theodorus D, 2008) Learning to adapt and accommodate for changes in interaction medium is required to improve professional acceptance and satisfaction with remote service delivery.

NHS Lothian highlighted the importance of planned implementation of video conferencing. Here, videoconferencing technology was initially procured for staff use and was rolled out across its locations onto staff desktop PCs. Following its successful implementation, and in response to staff feedback, work is now underway to extend its use into clinical settings. (Hill, 2010)

1.2.3.2Training

The current lack of comprehensive training for professionals, carers and patients in video conferencing applications constitutes an additional barrier to the acceptance and satisfaction of remote service delivery. The acceptance of video conferencing will depend on: prior training and information in the use of the technology and techniques to effectively communicate using this medium; generic training for understanding of the rationale for the use of this technology; and appropriate information and training on how to use the equipment; for professionals to develop a deeper knowledge and understanding of equipment to reduce setup, connectivity and trouble shooting issues. Styles recommended setting out guidelines from the outset regarding how successful communication will be achieved (Styles, 2008).

1.2.4Information Governance

Armfield raised the importance for consideration of security and privacy issues of video conferencing. (Armfield NR, 2012) Privacy and confidentiality are key concerns for healthcare service providers. Many of the local processes and procedures that govern online meetings will already exist for normal, face to face, consultations or meetings. For video conferencing this covers not only the actual meeting itself, but also what happens to any information associated with the meeting, for example: storage or sharing of documents, attendee lists, recordings etc, ownership of the information should also be considered. For the meeting itself, assuranceis required that the meeting will run safely i.e. that those present have a legitimate reason to be there. Patient consent for remote service delivery is a key concern. Obtaining informed consent may be a barrier to the implementation of remote service delivery when such information is not available, not supplied in an appropriate manner, or the provider does not have the technical competence to fully describe remote service delivery. Some populations who may benefit from remote services may not be physically or cognitively able to manipulate the technology, thus requiring someone else to assist them during the session. These situations may raise further issues of privacy, confidentiality, legal dilemmas and informed consent (Denton, 2003).

1.2.5Security

Data security and confidentiality is crucial for healthcare service providers. The use of video conferencing has raised several data security concerns. Panek et al outlined the following security requirements that should be considered:

• Authentication: Monitoring and verifying all the accesses to the information. A control over the users should be carried out at each access to the system, by utilising the users’ credentials (username and password) in order to verify that the user is who he/she claims to be
• Encryption: Scrambling a sender’s transmission according to an algorithm that the recipient then uses to unscramble and decipher the transmission
• Access control: Authorising access to specific and clearly identified resources to certain users based on their company responsibilities and the security classification of the resources
• Integrity: Developing or utilising applications and data management software that is secure from unauthorized modification of their code
• Confidentiality: Developing or utilising applications and data management software that is secure from disclosure to unauthorized persons or programs
• Auditing and accounting system: Monitoring the system and maintaining records of system and user activity
• Security policy: Establishing clear security policies for remote service delivery (Panek, 2002)

1.2.6Cost Analysis

Dependent upon the type of telerehab being performed and the complexity of the technology being used, the cost of establishing a remote delivery service may be a major barrier to its implementation (Hill, 2008). Some of the associated costs include the cost of developing the video conferencing system, the cost of training providers, and the maintenance of the technology and infrastructure (EdirippuligeWootton, 2006). Another cost barrier to the implementation of video conferencing may be the concern that there would be an increase in demand for services, thus multiplying the costs of the service (Hill, 2008). This concern is justified, especially given that the demand for AAC services is already increasing as a result of an ageing population and the associated increase in the numbers of people living with a disability (Winters, 2002). While the initial cost of establishing a remote delivery service may, in the long term, be less than the cost of continuing with current service delivery models, no definitive data exists in this area of cost benefit analysis (Hill, 2008).

1.3Limitations of the review

One of the limitations of the review is that it uses studies published in peer reviewed journals. It is documented that there is a bias towards studies that have positive findings. Therefore studies that do not demonstrate any effect or report a negative effect of remote service delivery may not be represented because they were not identified through the search. Grey literature was also excluded from the search. The literature review was also restricted by time and resources, requiring a targeted search strategy. Widening the search may have revealed further studies which looked at the use of video conferencing, remote access and telerehab tools applied in different fields. This may add to the body of evidence and highlight solutions to barriers and limitations.

1.4Future Research

Future research should continue to investigate clinical and operational aspects of telerehab using video conferencing. The studies all acknowledged the need for further research and gaps in the current evidence base, suggested studies include:

• technological requirements to support diagnostic protocols and intervention procedures
• further work on clinical efficacy and effectiveness
• further work on client, clinician, and caregiver satisfaction
• determination of client candidacy for remote service delivery
• a range of service delivery locations including controlled trials in laboratory settings and real-world locations such as clinics, schools, and client homes in both rural and urban areas.
• cost-benefit analyses
• practical implementation issues such as scheduling, workflow, sustainability and organizational readiness (Hill & Theodoros, 2002; Jarvis-Selinger et al., 2008; Krupinski et al., 2002, 2006; MashimaDoarn, 2008).

2References

Armfield NR, G. L. S. A., 2012. Clinical use of Skype: a review of the evidence base. Journal of Telemedicine & Telecare, pp. 18: 125-127.