Ellen Cohn

A Lexicon of Assessment and Outcome Measures for Telemental Health

BACKGROUND The purpose of this document is to provide initial recommendations to telemental health (TMH) professionals for the selection of assessment and outcome measures that best reflect the impacts of mental health treatments delivered via live interactive videoconferencing. MATERIALS AND METHODS The guidance provided here was created through an expert consensus process and is in the form of a lexicon focused on identified key TMH outcomes. RESULTS Each lexical item is elucidated by a definition, recommendations for assessment/measurement, and additional commentary on important considerations. The lexicon is not intended as a current literature review of the field, but rather as a resource to foster increased dialogue, critical analysis, and the development of the science of TMH assessment and evaluation. The intent of this lexicon is to better unify the TMH field by providing a resource to researchers, program managers, funders, regulators and others for assessing outcomes. CONCLUSIONS This document provides overall context for the key aspects of the lexicon.

Tele-AAC Resolution

Approximately 1.3% of all people, or about 4 million Americans, cannot rely on their natural speech to meet their daily communication needs. Telepractice offers a potentially cost-effective service delivery mechanism to provide clinical AAC services at a distance to the benefit of underserved populations in the United States and worldwide. Tele-AAC is a unique cross-disciplinary clinical service delivery model that requires expertise in both telepractice and augmentative and alternative communication (AAC) systems. The Tele-AAC Working Group of the 2012 ISAAC Research Symposium therefore drafted a resolution underscoring the importance of identifying and characterizing the unique opportunities and constraints of Tele-AAC in all aspects of service delivery. These include, but are not limited to: needs assessments; implementation planning; device/system procurement, set-up and training; quality assurance, client progress monitoring, and follow-up service delivery. Tele-AAC, like other telepractice applications, requires adherence to the ASHA Code of Ethics and other policy documents, and state, federal, and international laws, as well as a competent technological infrastructure. The Working Group recommends that institutions of higher education and professional organizations provide training in Tele-AAC service provision. In addition, research and development are needed to create validity measures across Tele-AAC practices (i.e., assessment, implementation, and consultation); determine the communication competence levels achieved by Tele-AAC users; discern stakeholders’ perceptions of Tele-AAC services (e.g., acceptability and viability); maximize Tele-AAC’s capacity to engage multiple team members in AAC assessment and ongoing service; identify the limitations and barriers of Tele-AAC provision; and develop potential solutions.

Making the Case for Uniformity in Professional State Licensure Requirements

Telehealth, the use of communication and information technologies to deliver health services, was initially envisioned as a way for persons in rural or remote settings to receive otherwise unavailable healthcare services. Now, in addition to overcoming personnel shortages for underserved populations, telehealth shows promise in meeting the needs of a constantly mobile U.S. society and workforce. Fortunately, telerehabilitation can meet the needs of a mobile society and workforce by enabling continuity of care for individuals who are out-of-town, on vacation, in temporary residence as a university student, or on business travel. Unfortunately, outdated legislative and regulatory policies and inhospitable infrastructures currently stand in the way of a seamless continuum of care. In 2010, the American Telemedicine Association’s Telerehabilitation Special Interest Group (TR SIG) convened a License Portability Sub-Committee to explore ways to diminish barriers for state licensure portability with a particular focus on physical therapy, occupational therapy, speech therapy, and audiology. In 2011, the Subcommittee published a factsheet (1) that detailed the challenges and potential solutions that surround the difficult issue of licensure portability. Concurrently, the American Telemedicine Association is advocating for national reform of professional licensure. (2) At the heart of all licensure requirements is the ability to determine who should be granted the authority to practice in a particular profession. This is done by focusing on educational, examination and behavioral requirements that are deemed the minimum necessary to protect the public from harm. States, however, with whom authority for licensure of health professionals rests, have independently defined those minimum requirements. This approach has led to a myriad of requirements that vary from state to state. Licensure portability will best succeed when variability between licensure requirements is minimized and an efficient licensure process exists. In this paper, these two critical factors for licensure portability are referred to as “licensure requirements” and “the credentialing process.” Currently the variability between both of these factors is different between professions as well as between jurisdictions. To find the best solution to licensure portability, it is critical to determine which of these two elements create significant barriers for licensure mobility. This document outlines a method for the professions to begin collecting data to pinpoint the areas where agreement and variations exist in licensure requirements and processes between states. Such information will inform efforts towards uniformity.

Why Image the Velopharyngeal Portal

This book deals mainly with the applications and interpretations of a radiographic technique, multiview videofluoroscopy of the velopharyngeal (VP) portal. This procedure is used to evaluate the effectiveness of velopharyngeal closure in patients with speech evidence of velopharyngeal insuffiency1 (VPI), and in so doing, provides precise anatomic and physiologic information as to how the VP portal functions during phonation. The data derived by this technique are useful in assisting clinicians to determine the most appropriate course of therapy for each patient.

Resolving barriers to licensure portability for telerehabilitation professionals.

Rehabilitation professionals (e.g., audiologists, occupational therapists, physical therapists, speech-language pathologists, etc.) can only engage in telerehabilitation in states in which they hold a professional license. The current state-based licensure and regulation of rehabilitation professionals does not facilitate the practice of telerehabilitation across state lines. Given today’s equipment capabilities and consumer adoption of the electronic delivery of many kinds of services, health care providers, including rehabilitation professionals, should be able to serve clients wherever they are needed.

Nasolabial fold discontinuity during speech as a possible extended cleft phenotype.

Objective This exploratory research sought to extend the cleft phenotype by identifying movement-related soft tissue appearance changes in the midfacial region in individuals with cleft lip/palate or those with genetic susceptibility to cleft lip/palate (unaffected relatives). The cleft phenotype (clinically identified orofacial cleft or subclinical orbicularis oris defect) was hypothesized to be associated with movement related appearance changes in the midfacial region, e.g., with furrowing and dimpling during speech. Design Changes in the appearance of skin in the midfacial region, including a newly identified phenotypic feature, nasolabial fold (NLF) discontinuity, were described and compared across groups. Participants Individuals with cleft lip (n = 42), unaffected relatives of persons with a cleft (n = 57) and healthy controls (n = 41) were compared. Results Frequencies of NLF discontinuity differed across cleft, relative, and control groups. NLF discontinuities were observed more frequently in individuals with a cleft phenotype (overt cleft or previously identified orbicularis oris muscle defect) than in those with no underlying muscular defect (Fisher exact test, P = .014). Conclusion Results suggest that the appearance of facial soft tissue during movement of the midface is moderated at least in part by underlying cleft risk factors, indicating certain facial movements as candidate physical markers for extension of the cleft phenotype.

Techniques of Multiview Videofluoroscopy

In Chapter 3 we briefly described the three basic views — the lateral, the frontal, and the base — so that the reader could appreciate the rationale behind the choice of the equipment with which to perform this procedure. This chapter will describe information provided by each of the views, methods of performance, and normal anatomy as seen in each of the views.

How to Image the Velopharyngeal Portal

In order to determine the best method of imaging the velopharyngeal portal so as to appreciate the interrelationships of palatal and pharyngeal wall movements during speech, one must consider the purposes of the examination: First is the desire to image the velopharyngeal (VP) portal; second, the desire to image the portal in motion; third, the desire to image it while simultaneously recording the patient’s speech. If the method of imaging the VP portal does not satisfy all three of these requirements, the study will give less than adequate diagnostic information and inappropriate therapeutic decisions may result.

American Telemedicine Association’s Principles for Delivering Telerehabilitation Services

Telehealth is a broad term used to describe the use of electronic or digital information and communications technologies to support clinical healthcare, patient and professional health related education, and public health and health administration. Telerehabilitation refers to the delivery of rehabilitation and habilitation services via information and communication technologies (ICT), also commonly referred to as” telehealth” technologies. Telerehabilitation services can include evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation, and coaching. Telerehabilitation services can be deployed across all patient populations and multiple healthcare settings including clinics, homes, schools, or community-based worksites. This document was adapted from the American Telemedicine Association’s (ATA) “A Blueprint for Telerehabilitation Guidelines” (2010) and reflects the current utilization of telerehabilitation services. It was developed collaboratively by members of the ATA Telerehabilitation Special Interest Group, with input and guidance from other practitioners in the field, strategic stakeholders, and ATA staff. Its purpose is to inform and assist practitioners in providing effective and secure services that are based on client needs, current empirical evidence, and available technologies. Rehabilitation professionals, in conjunction with professional associations and other organizations are encouraged to use this document as a resource for developing discipline-specific standards, guidelines, and practice requirements.

Interpretation of the Videofluoroscopic Study

Years ago there was a coffee and doughnut shop in New York City called “Mayflower,” which emphasized as part of its advertising slogan that one should keep an eye on the doughnut and not on the hole. In analyzing videofluoroscopic studies, we, on the other hand, should pay equal attention to the hole (velopharyngeal portal) and the doughnut (palate and pharyngeal walls ringing the VP portal). When the sphincter does not close, there is a hole. Unlike the doughnut, however, this hole is not symmetrically round but has different contours along different margins. In order to understand the manner in which the velopharyngeal portal closes, we must examine the contributions that the palate (velum) and pharyngeal walls each make. This understandably is best appreciated by examining the component movements of the palate and pharyngeal walls in the lateral, frontal, and base views.