Overview

• This project aimed to improve timely identification and treatment of childhood hearing loss by implementing a mobile health (mHealth) hearing screen followed by expedited telemedicine referral for follow-up diagnosis and treatment.

Organization Name

Norton Sound Health Corporation

Organization Type

• Public Health System
• Rural health system

National/Policy Context

• Rural Alaska, where the population is primarily Alaska Native, experiences a disproportionately high burden of infection-mediated hearing loss compared with the general US population.
• Barriers to care exacerbate the alarmingly high prevalence of hearing loss in rural Alaska. Spanning 586,000 square miles, 75% of Alaskan communities are not connected to a hospital by road, necessitating travel by plane or boat to be seen by a specialist. Population sparsity (1.1 per square mile) and a low ratio of doctors to residents contribute to pervasive delays in care.
• In response to these challenges, tribally owned regional healthcare systems have developed an extensive network of village health clinics staffed by community health aides (CHAs) to provide basic healthcare services in remote communities.
• Additionally, telemedicine technology has been adopted in Alaska over the past 15 years to improve access to care. A statewide telemedicine network allows consults to be read remotely by specialists in an asynchronous fashion. Through telemedicine, a specialist can direct care provided by CHAs in the community or expedite travel to a regional center if necessary, bypassing potential delays in care.
• Early in its adoption, asynchronous or ‘store and forward’ telemedicine consultation was validated as equivalent to in-person examination for ear and hearing problems.

Local/Organizational Context

• While telemedicine technology has been used to triage ear and hearing problems in communities for many years, it has never been used in the school hearing screening referral process.

Patient Population Served and Payor Information

• The patient population served are school-aged children (age 4-21 age) in the Bering Strait School District (BSSD) in the Norton Sound region of rural Alaska.
• Nearly the entire patient population qualifies for free or reduced-price lunch and Medicaid eligibility.

Leadership

• Local school leadership and clinic staff managed the referrals.

Funding

• The project was funded by the Patient-Centered Outcomes Research Institute, a non-governmental organization that supports patient-centered comparative effectiveness research and represents a collaboration between Norton Sound Health Corporation, Duke University and Johns Hopkins University.

Research + Planning

• This intervention was developed with Alaska stakeholder and community input, including parents, teachers, administrators, community health aides, children, and community leaders.
  • Community engagement in the form of focus groups and semi-structured interviews were used to gain community and stakeholder perspectives on the intervention.
• A leadership team met weekly via teleconference to review study progress, data quality, and participants’ safety.
• Trained audiologists and ENT surgeons were hired, teachers were trained to do the school screenings, and a study team was created to perform mHealth screenings.

Tools or Products Developed

• HearScreen: A validated smartphone-based hearing screen used in the mHealth screening intervention.
• Shoebox: A validated mHealth tablet audiometer, an Otometrics tympanometer, and an Otometrics Otocam digital otoscope used in the audiometric assessment portion of the intervention.
• HEAR-QL questionnaire: The only validated tool available for hearing-specific quality of life in children 7-18 years of age.
• AIMSweb: A validated, reliable measure of math and reading performance that is administered to all children in kindergarten to 8th grade three times annually in BSSD.
• REDCap: A secure, encrypted web-based platform suitable for multi-institutional research studies that was used in this study for data entry, importation of data from multiple external sources, auditing of data manipulation and automated exporting of data to statistical packages for analysis.

Training

• Members of the study team other than trained audiologists were trained to perform the mHealth screen.
• Audiologists and ear, nose and throat (ENT) surgeons were trained to read telemedicine consults within the Alaska Native healthcare system while other study team members were trained to perform medical record abstraction.
• Local school leadership and clinic staff were trained to manage referrals.

Tech Involved

• Electronic medical record
• Redcap
• Telemedicine software
• Telephone

Team Members Involved

• Physicians
• Support Staff

Workflow Steps

• With the current school screening protocol, which happens annually, school staff place a soft tip in the ear and record a pass or refer for each ear. If the child does not pass the criteria in one or both ears, the child will be referred.
• On the same day that students receive their annual hearing screen, they also undergo the mHealth school screening protocol. This includes a pure-tone screening at standard frequency using hearScreen (a validated smartphone-based hearing screen) and an assessment of middle ear function using a tympanometer. If the child does not respond to tone, a rescreen at that frequency will be performed at the end of the screening. If they do not pass a second time, a referral is generated.
• The third testing the child undergoes is an audiometric assessment using Shoebox, a validated mHealth tablet audiometer, Otometrics tympanometer, and Otometrics Otocam digital otoscope. Trained audiologists perform this assessment.
• The schools then generate a list of all children referred by the current screening protocol, and a list from the mHealth screen of children who refer either by pure-tone screening or tympanometry.
• The referral list is given to local school leadership and clinic staff. Referral pathways include CHA (community health aide) or ENT (ear, nose, throat surgery).

Budget Details

• Cost of time spent by IT making adjustments to the EHR (electronic health record)
• Material costs used in mHealth school screening (hearScreen, the smartphone-based hearing app) and audiometric assessment (Shoebox, tablets used as audiometers).

Where We Are

• Project is ongoing.

Outcomes

• Time to diagnosis from screening date: Time to ear/hearing diagnosis from screening date is measured in days via chart review. This decreased from an average of 4.2 months (18 weeks) to 2.5 months (10 weeks) when telemedicine was implemented.
• Sensitivity and specificity of current school and mHealth screening protocols: These measures were compared to a benchmark audiometric assessment (air and bone conduction audiometry, tympanometry and digital otoscopy).

Benefits

• This intervention proved the effectiveness of current school screening programmes in Alaska and represents a unique opportunity to evaluate a new school screening protocol that uses mobile health (mHealth) based screening tools and telemedicine referral in a remote region of Alaska where telemedicine has already been standard practice for triage of health concerns for over 15 years.

Unique Challenges

• The time frame of annual screening and referral interventions was over 2 academic years, which limits the possibility of adapting other design features such as step-wedge or waitlist control for telemedicine referral process.
• Study limitations:
  • Lower statistical power and precision because the project was evaluated using a cluster randomised trial
  • Selection bias, imbalance between study arms, and generalisability (challenges common to cluster randomised trials)
  • Also, because of the nature of the intervention as a referral process, there was the challenge of masking children and parents to allocation after the school screening day.

Sources

• Emmett SD, Robler SK, Wang NY, Labrique A, Gallo JJ, Hofstetter P. Hearing
  Norton Sound: a community randomised trial protocol to address childhood hearing
  loss in rural Alaska. BMJ Open. 2019 Jan 15;9(1):e023078. doi:
  10.1136/bmjopen-2018-023078. PubMed PMID: 30782695; PubMed Central PMCID:
  PMC6340015.
• Kokesh J, Ferguson AS, Patricoski C. Preoperative planning for ear surgery using store-and-forward telemedicine. Otolaryngol Head Neck Surg. 2010 Aug;143(2):253-7. doi: 10.1016/j.otohns.2010.04.265. PubMed PMID: 20647130.
• Umansky AM, Jeffe DB, Lieu JE. The HEAR-QL: quality of life questionnaire for children with hearing loss. J Am Acad Audiol. 2011 Nov-Dec;22(10):644-53. doi 10.3766/jaaa.22.10.3. PubMed PMID: 22212764; PubMed Central PMCID: PMC3273903.