Bopanna Ballachanda, PhD, holds a doctoral degree in auditory neurophysiology and was the founder and CEO of a large multi-state practice with clinics in Arizona, New Mexico, and Texas, where he found teleaudiology to be a useful tool. He has retired from private practice and, in addition to serving on several boards and working as an adjunct professor, he now serves as a consultant to audiology practice owners who wish to delve into teleaudiology. Here, he shares with The Hearing Review his perspective on what teleaudiology has to offer, why more hearing care practices haven’t taken advantage of this technology, and why he thinks they should.
The Hearing Review: Can you tell me a bit about your involvement and interest in teleaudiology, and why you’re so passionate about it?
Bopanna Ballachanda: I opened a practice in Taos, New Mexico, which was quite a ways away from my main practice in Albuquerque—a 2 ½-hour drive. When I opened the practice, we had a very limited number of patients, and one day I had just one patient scheduled, but I drove all the way from Albuquerque to Taos. And guess what? The patient didn’t show up. So I had to turn around and drive all the way back to Albuquerque. And on the way I thought, There must be a better way to address this long-distance patient care.
I did some research, and I saw that telepractice was being done in psychiatry and in other fields that they felt that they could reach patients at a distance. And I thought I should be able to do it. Then the challenge was how to implement this process, and I did.
So that was the beginning of my passion for telepractice. And it was quite successful because I was able to reach patients on a day that it was slower in Albuquerque and a patient had a problem in Taos. I moved to a hybrid system, where I visited the Taos clinic one day a week, and would do telepractice from my clinic in Albuquerque on other days if there was a crisis that my assistant could not handle or if they needed testing to be done in a remote location.
HR: Many hearing care clinics may be content with doing things the old-fashioned way, without telehealth. Why should they start using teleaudiology? What are the benefits to HCPs and patients that they might be missing out on?
Ballachanda: The advantage as a practitioner is, number one, reduced travel time to see more patients because we can make use of when we have some downtime in a clinic, like I did. When I didn’t have patients scheduled in my Albuquerque office, I could see patients in the clinic in Taos using teleaudiology.
It is also financially advantageous. The satellite office you establish doesn’t have to be a full-fledged, large-scale building. It could be a small place with all the equipment necessary to do the testing. It can even be a joint venture with other specialties, or it could be a standalone small location.
Especially in remote locations in the United States, an audiologist cannot afford to have a full-time practice in a small town because there aren’t enough patients to take care of. But a well-managed satellite clinic can function as well as a main clinic. And you can hire one part-time employee to run it for a limited amount of time per day or per week.
The audiologist doesn’t need to spend hours driving to the location and back, which also saves time and money. If you really look at the 5 hours that it would take for me to drive up to my Taos clinic and back, I could have seen two to three patients in that time. If you look at how much you need to make per hour to keep your practice going, it’s quite expensive.
Teleaudiology also promotes a better culture for the practitioner as a leader in the field of hearing care. This is a positive image that they’re reaching more patients and taking care of them.
From the patient’s point of view, when they are at a satellite clinic, and an audiologist uses telepractice to interact with them from another location, the patient feels that their problems have been addressed by the specialist rather than being taken care of by an assistant or someone who is not as qualified as the primary practitioner. The patient feels respected.
The patient can also set up a time that is convenient for them and doesn’t involve a lot of waiting. And some of the hearing aid issues can even be done at their house. It can sometimes be resolved now with a smartphone, especially for follow-up, so the patient doesn’t have to do a lot of traveling. If someone does need to drive the patient to appointments because of limited mobility or other issues, then only having to drive the short distance to a satellite office, or not having to drive to an office at all, is much more convenient for everyone involved. So those kinds of things can be minimized, and that’s a big advantage for the patients. The patient’s point of view is it’s convenient.
HR: It’s great that so much of what an audiologist does can now be handled remotely. What does teleaudiology encompass today, and how has that changed?
Ballachanda: That’s a good question. Teleaudiology has evolved a lot.
Early on, it was more used for diagnostic testing. Now it’s possible to use video otoscopes, do hearing screening, consultation, and answer questions from the patients. And people are using it for tinnitus management, hearing aid programming, and hearing aid issues. A cochlear implant is also now able to be programmed remotely. Things are changing.
The only place that we have not been able to do a whole lot is in testing and treating balance function because it requires an expert’s care, as someone needs to be there to direct the process. Otherwise, can do lot of testing for patients.
Things are getting better, largely thanks to the COVID-19 pandemic, which opened up this avenue. Before that there was so much reluctance from hearing care professionals to do telepractice. Some worried that remote visits would replace in-person visits and have a negative effect on audiology clinic revenue. But that was proven not to be the case. Now, HCPs are starting to be more open to it, and I expect the technology will continue to evolve and improve to make telepractice even more beneficial.
Further reading: Teleaudiology Today: An Interview with Authors Vinaya Manchaiah and De Wet Swanepoel
HR: What are some of the barriers to audiology clinics using teleaudiology, and how can they overcome them?
Ballachanda: First is technology implementation. That includes all the equipment for testing and other clinical tasks that will need to be at the satellite office and the equipment that’s necessary to communicate between the two clinics and other related instruments. That is important for having two-way communication. They have to bring in equipment that can talk to the computer there, which in turn talks to the computer at their remote location. But as long as you can communicate between clinics, you can start with some equipment, and add more later. There are many resources available that can help HCPs with setting up a clinic for teleaudiology, including a step-by-step article I wrote for The Hearing Review.
The second part is having good help, because the audiologist needs someone to follow certain instructions and follow the directions for testing, and who is able to do all the things that the audiologist wants them to do.
This is something that’s in the process of changing because each state has a different version of what this assistant looks like. We need to standardize it. This personnel role is to help the audiologist and facilitate a good clinical experience. Some places they call the person in this role an assistant, some places a technician. So there is work to be done on that and it’s just a matter of how we define the roles and qualifications and how they can help audiologists do their job.
We are seeing a shortage of audiologists added to this whole mix of challenges we have, so an audiologist can do a lot more if they have a support system to help them with diagnoses and help them out with many of the necessary clinical tasks.
The third dimension is state licensure laws. A person who’s not licensed in a state cannot practice there at this time, even virtually, but there are some attempts to change that by having a state licensure compact. If that happens, and states have agreements for licensed audiologists to practice in each other’s states, they might be able to reach out to their patients using telepractice when they’re in another state.
Those kinds of things are quite critical when, for example, patients from the northern region of the United States travel to the southern region during winter months. That becomes helpful if audiologists can reach out to their patients who are far away and take care of their needs without having to go through another audiologist who is physically in that location to help them during that time.
I hope that some of these issues can be resolved soon to help expand the use of teleaudiology.
Further reading: Teleaudiology And Hearing Aid Care: Consumers Are Satisfied, Why Aren’t We?
HR: What do you see as the future of teleaudiology, and what do you think will help the profession get there?
Ballachanda: The advantage of telepractice in the broader sense is to reach out to the millions of people who have not had a chance to go to a clinic or to a place where they can get hearing tests and get an understanding of what kinds of hearing challenges they’re facing. So this will expand the reach to most of the patients in the United States and worldwide. Wireless technology is moving at a very fast pace and that should help us to reach more patients and provide more ways of helping people. I’m expecting that teleaudiology will have a place in the future and will facilitate better care, patient satisfaction, and a better place for the audiologist to work.
But the future of hearing care requires a lot more audiologists than what we have now, and what we are producing right now. So how do we address this shortage and how do we provide the best care that the patients deserve? So this needs to be looked into from that point of view.
And I expect telepractice to advance beyond more than just testing and recommending some kind of a treatment protocol. I imagine the hearing aid being able to receive messages regarding when to change batteries, taking them out. And for patients who have challenges with memory issues, we can be holding their hand as a guide in many ways with this connectivity that we have without making it more challenging for the patient. They could be instructed on many things, such as taking their medication. It’s futuristic, but it might make things easier for a lot of patients. Also, monitoring the use of hearing aids (sensory deprivation) could allow us to track a possible connection to the onset of memory issues due to lack of use of amplification devices.
Another major way that telepractice could change in the future is by allowing audiologists to be able to tell what might be causing a person to have difficulty hearing and understanding in noise, versus in a quiet setting. With the right sensors and other technology to transmit information, I think it becomes a window to their listening experience.
If I can stretch a little bit with imagination and futuristic thinking, can we address some hearing issues in a noisy place like when the patient is in a restaurant? Can we do any real-time programming using some newer technology? Could we check and see whether teleaudiology can help identify the noisy places for industrial workers? Can we keep track of what’s going on by using certain sensors? Is there any way we can understand what happens when a person who is able to hear well in a quiet place but when they go to a noisy place they have a hard time hearing so we can understand what the signal-to-noise relationship is?
From the point of view of a practitioner right now, what we do is more static. Patients come in and they tell us what’s going on, and we in the clinic try to understand what could be going on in an active, dynamic situation. So we could go from being in a static state, with a very limited understanding of the situation, to a future where we can go into a dynamic processing of what’s going on with a patient’s hearing in a noisy environment.
So that’s a big leap in our professional care, from treating a problem based upon symptoms to addressing what the root cause of all these symptoms is.
HR: What resources do you suggest for those interested in learning more about teleaudiology and how they can make use of it in their practices?
Ballachanda: There are several places where they can get details on what needs to be done to start implementing telepractice.
I recommend reading my other articles in The Hearing Review about teleaudiology, including, “How to Use Teleaudiology Technologies in a New Setup or in an Existing Office.” And I’m looking forward to being involved in helping develop more articles about teleaudiology for The Hearing Review that will look at many of the different aspects of this exciting, evolving way to help more people.
Consultants and other audiologists who have experience with this can also help clinics to successfully implement telepractice. And the manufacturers of testing equipment, for example, can also help them establish ways to use the devices and technology remotely.
The American Academy of Audiology and ASHA also have position papers about teleaudiology on their websites that are good resources.
If you’re interested in using teleaudiology, it’s important to do a feasibility study first, which I’ve covered in what I’ve written for The Hearing Review. Is it worth doing? Would it mean saving time and money for the HCPs and the clinic? Are there enough patients far away who would benefit? If you determine it is worth it because there is an advantage to the hearing care professional and the patient, then I would say jump in, and you can keep adding more types of equipment and functionality as you go.
There are a lot of advantages to telepractice, as long as we do it in the right way. Telepractice can provide better patient care and patient experience, and better service and financial stability for the practitioner.
Photo: Bopanna Ballachanda, PhD
Original citation for this article: Teleaudiology Benefits and Barriers: An Interview with Bopanna Ballachanda, PhD. Hearing Review. 2024;31(4):24-26.
