Overall goals of the Working Group
- The coordination and scientific and clinical development of the National Network of Teleaudiology.
- Hearing implants’ telefitting is a clue component of postoperative patients’ health-care, by providing the optimum auditory nerve electrical stimulation parameters.
- By providing state-of- the-art telemedicine solutions, it enables reduced medical costs for otolaryngology, the ability to conduct remote consultations, conferences, treatments and rehabilitation without the need for specialists or patients to travel all over the country.
- Support for physicians and other specialists from smaller medical centers, creating the opportunity to experts assistance in Africa, Asia, Australia, North America, South America.
- Improved qualifications of less experienced medical staff watching the work of the experts: organizing Windows Approach Workshop.
- Hearing screening around the world. Screening was performed using the Platform of Sensory Organs Examination; on the basis of the audiometric procedure of measuring the hearing threshold.
- Actively participates in didactic activity on the Speech Therapy and Audiology specialization run at Maria Curie-Skłodowska University, as well as takes care of specialists undergoing the trainings.
One of the major technological breakthroughs in the telemedicine development by Institute of Physiology and Hearing Pathology, took place in 2007. This huge step forward was the creation of a telefitting pilot study. Over the years, the Institute has developed and deployed to clinical practice system that will enable the creation of a network of cooperation abroad centers and throughout the country - the National Network of Teleaudiology in 2009.
To obtain the best hearing beneﬁts after cochlear implantation, the speech processor must be optimally ﬁtted. The majority of patients have been implanted and are unable to receive correct implant fitting. They have to undertake a long trip to the cochlear implant clinic, and this incurs high cost, time, and travel weariness. To overcome this problem, ‘teleﬁtting’ has been proposed.
Remote fitting of the cochlear implant system
Four PC computers are used for the remote fitting method: two on the patient’s side and two on the specialist’s side. On both sides, internet cameras, microphones, and loudspeakers are used to provide communication between the patient and the specialist. One of the computers on patient’s side is equipped with clinical interfaces to provide communication with the speech processor and the implant.
The patient’s speech processor is connected to the clinical interface on computer at the distant polyclinic. The fitting specialist, working on computer in the International Center of Hearing of Speech, using a remote desktop application, takes control of patient computer via an internet connection. It is now possible to start fitting the software and to perform any actions necessary for measurements and fittings. The communication between the specialists and the patient is secured by the use of an audio-video connection over the Internet. On the patient’s site there are also support specialists — speech therapists, etc., providing help for the patient in the process of communication with the specialists. Commercially available software is used for the remote desktop and audio-video system.
After the session, the support specialist disconnects the processor from the interface and gives the patient a new processor with the programs.
Teleservice of speech processors and hearing aids
• Telemetric measurements to check the internal part of the system
• Objective measurements: electrically elicited compound action potentials
• Programming electrical stimulation parameters into the patient’s speech processor
• Activation of the speech processor in ‘live’ mode
• Consultation about ways to use new settings in the speech processor:
- Remote objective measurements (ECAP, ESR, Telemetry)
- Remote psychophysical measurements (amplitude growth function, threshold detection)
Hearing implants’ fitting is a clue component of postoperative patients’ health-care, by providing the optimum auditory nerve electrical stimulation parameters. Often, the need for a regular visits in the Institute involved a long and time-consuming, two-direction journey. As the majority of our patients are children, they were usually exhausted by the trip. This situation influenced negatively patient’s performance during hearing test evaluations, which were of reduced reliability. Such situation translated sometimes into suboptimal hearing implant fit. Additionally, the whole family had to incur high travel expenses, which were a significant burden in many cases.
In 2004, the Home Rehabilitation Clinic was established. Its primary aim was to improve the rehabilitation effectiveness in children with hearing impairments. Additionally, the founders wanted to reduce the high medical and educational expenses of the treatment process. At first, special materials dedicated to parents were prepared, which enabled better understanding of the individual work with a child in home. The next stage in the development of the Home Rehabilitation Clinic was setting up of a program aimed at both patients (including children and their parents) and specialists from all over the country (teachers and educators and students). The clue of the program was to utilize the knowledge, experience and achievements of the multidisciplinary Institute’s team, to develop effective national therapy programs. These ideas are realized to this day through the cooperation of the Center for Observation and Management - Program Coordinator with Regional Centers - Program Implementers via the Internet connection network.
Successful development of the Home Rehabilitation Clinic proved the effectiveness of teleconsultations, relerehabilitation and teleeducation combination. The substantial contribution of various specialists to the program, allowed for joining educational influences with running supervision of the therapy course, including an insight and direct commentary on the observed patient, parent or guardian. In conclusion, the Home Rehabilitation Clinic program is highly accessible and provide different types of consultations according to individual patient’s and parents’ needs.
Creation of the brand-new methods of cochlear implant telefitting system and the use of the Internet in the telerehabilitation process, was possible thanks to intense research, in particular the development of:
- cochlear implant teleffiting procedure using Internet connection
- methods enabling carrying out a series of psychophysical and objective measurements necessary to make a diagnosis
- effective schedules of hearing and speech rehabilitation
- testing and selecting the necessary hardware and software for use in telerehabilitation procedures
- reliable tools used for monitoring the satisfaction of patients and professionals involved in the method
NATIONAL NETWORK OF TELEAUDIOLOGY
The process of diagnosis, rehabilitation and post-intervention care over patients with hearing impairment, frequently equipped with various kinds of hearing prostheses, usually requires an experienced, multidisciplinary team to undertake repeated sessions with the patient in the clinic. Its entails often long travels to medical center, associated with costs and time-consuming. To reduce patients’ burdens, the Word Hearing Center’s team introduced in 2009 the National Network of Teleaudiology (NNT). The establishment of the National Teleaudiology Network has been in close collaboration with a number of clinical centers in the country. This cooperation deals with both clinical work and new research activities implemented within the Network. Scientific partnerships also include clinical-research centers and medical companies with whom telemedicine research has been done in the past: Spain, Germany, Greece, Switzerland and Austria.
Aims of the National Teleaudiology Network
Versatile care for patients after cochlear implant, audiotory brainstain implant, middle ear implant, bone conductive implant and also modern hearing aid using a programme of the complex and comprehensive health care and matched to the individual needs of every patients.
Coordination of the hearing rehabilitation process that is necessary for development of sound perception and interpretation abilities, and, through systematic training, making speech communication with other people possible
Realization of social, educational, and professional development programmes based on knowledge and experience of the multidisciplinary team of specialists in the Institute of Physiology and Pathology of Hearing
Spread of knowledge about cochlear implants and the rehabilitation process of implanted patients.
Technological facilities in National Teleaudiology Network
Multipoint Control Unit RMX2000 video conferencing system, which is a central unit that enables the audio-visual connection of two or more centers together
23 telemedicine offices based on HDX8006 video conferencing bridges, LCD panels and Internet-enabled computers equipped with clinical diagnostic interfaces, impedance audiometers and the necessary software. Video conferencing bridges enable high-quality video and audio streaming, tailored to the capabilities of the Internet connection. Clinical diagnostic interfaces are used to connect hearing implant systems to a computer, and, consequently, to access these systems by an expert via the Internet
Modern Telemedicine Studio OTX300, which is the center of the National Teleaudiology Network, and allows for convenient simultaneous connection with many centers and conducting various teleconsultations at the same time
Each component of the system is connected by a fast Internet that provides high quality of video conferencing and trouble-free remote desktop applications functioning.
At present, the National Teleaudiology Network uses state-of-the-art software and videoconferencing equipment, together with unique testing, measurement and selection procedures for electrical stimulation fitting. It enables the cooperation of specialists from many fields: clinical engineers, physicians, speech therapists, psychologists, to provide the best postoperative care to patients, including hearing implants users. Such a solution is extremely convenient for patients, who save a huge amount of money, nerves and time, visiting the medical centers located nearby their home.
Medical centers collaborate with NNT
Aim of the National Network of Teleaudiology is providing a wide range of telehealth applications like telefitting, telediagnostics, telerehabilitation, or teleeducation. It consists of 21 cooperating centers in Poland and 4 abroad in the Ukraine (Odessa and Lutsk), Belarus (Brest) and Kyrgyzstan (Bishkek). The center of the network is the International Center of Hearing and Speech in Kajetany, from where experienced specialists provide telecare for patients in cooperating polyclinics. Over the years, NNT was repeatedly proven in exceptional situations when, for example, a hearing prosthesis/processor of implant was damaged, and when it was necessary to change its parameters
First type testing a patient and then transferring the results via emailing or the Internet to a professional that will look at the results or teleconsultation. Teleconference equipment provides audio and video connection while remote desktop application allows to take the control over the distant computer and perform all necessary measurements.
Second type testing a patient in real-time as if the patient is sitting in front of you. Audiologists are used to testing patients remotely because testing a patient in a sound booth while the audiologist sits outside the booth is virtually the same as testing a patient over the Internet. The window is not a real glass window but a teleconference window. The only real difference is that the physical distance changed.
Audiology centers which starts to introduce the objective methods like ABR and otoacustic emission (OAE) as a part of diagnostic procedures for comprehensive hearing evaluation, encounter some problems with the testing procedures. Specific characteristic of the electrophysiological brain stem response ABR, requires fallowing very strict procedures concerning stimulation and acquisition parameters which can have negative impact on the quality of registered parameters and test outcome. In such situation very important is the experts advise which can help in finding the right way to solve the problems. This was the main reason of introducing objective methods of hearing assessment and advanced methodology in telerehabilitation in to 3 clinics abroad – in Ukraine, Belarus and Kyrgyzstan newly added to the National Network of Audiology.
Before starting the examinations local technicians completed comprehensive training courses. They were instructed on the correct patient preparation for testing, abrasions of the skin, electrode sticking, clip attaching, and launching of the appropriate software. Support documentation was prepared. After the test, the results are collected and sent to a specialist in Poland to determine the result. This technology assists clinicians by making it easier for them to consult with other more experienced audiologists.
Telemedical diagnostic-rehabilitation systems Health
TeleZdrowie is a biggest portal offering the harvest of telemedical diagnostic-rehabilitation systems Health. This portal was drawn up in the cooperation of the Cathedral of Multimedia Systems of the Gdańsk technical university and the Institute of Physiology and Pathology of the Hearing. The following systems are available:
"I CAN HEAR" - The system "I CAN HEAR..." is a multimedia computer programme.
The role of the "I CAN HEAR..." system is mainly to test the hearing mainly in children and youth. The tests uses automatic questionnaire analysis, audiometric tone test procedure and testing speech intelligibility in noise. To carry out the tests, you will need, in addition to a PC, audiometric headphones and a calibrator. The calibrator is a small electronic device and comes together with a set of headphones.
“ I CAN SPEAK” - The Universal System for Testing and Rehabilitation of Speech is a multimedia website devoted to the problems of articulation. It is designed to improve the effectiveness and availability of diagnostic and rehabilitation methods used in phoniatry and speech therapy. Speech - the ability to receive and produce language messages - is how humans communicate using sound. The perception of utterances involves the process of hearing and language analysis which leads to the discovery of content. The production of speech begins in the brain when thoughts are formed and processed into signals that control the mechanical motion of articulators. The process activates other organs that are part of speech production: lungs, larynx, and articulators above the larynx (tongue, soft palate, mandible, lips) that make up the articulatory channel (tract).
“I CAN SEE” - System of the eye test \ "I can see... \" is multimedia computer programs. System \ "I can see... \" is intended the eye test of both adults, and children and teenagers. Eye test is based on the automatic analysis of the questionnaire form, the test of the colourful vision, the test of hidden squint and the test of diversifying the contrast.
Nowadays, audiology and otolaryngology, which are included in preventive medicine, now have many possibilities to assist patients with hearing impairment. However, in order to make full use of these opportunities, hearing disorders or damage should be detected in the early stages. Telemedicine makes possible to monitor many groups, especially children. It gives also the possibility to conduct mass population examinations in this age group as an instrument of national health policy and decrease the costs of healthcare system.
One of the priority activities of the Teleaudiology Working Group is a screening program for children of all ages in collaboration with numerous national centers. We developed methods, procedures and devices for carrying out them. Chairmen are the coordinators of many programs.
Platform for Sense Organs Screening
In 2008 was developed by the Institute of Physiology and Hearing Pathology in cooperation with the Institute of Sensory organs new multimedia tool used in screening – Platform for Sense Organs Screening.
The platform is built around an internet network solution, interfacing a central computer system and a series of portable computers (remote client devices) equipped with audiometric headphones and a response-button interface. The platform allows the user to conduct the following tests:
Audiometric testing: This feature allows the user to perform air conduction audiometric testing for each ear separately, in a tone frequency range from 250 to 8000 Hz and for hearing threshold levels not exceeding 80 dB HL.
Speech screening: The speech test is carried out to obtain reliable information on: (i) the quality of verbal behavior of the child and (ii) the degree of speech development (or of any potential delays) and any pathological linguistic phenomena occurring in the speech of the child.
Audiological survey: This module allows the user to conduct a general survey regarding the hearing, sight, and speech of a patient. The surveys were developed by specialists based on years of experience in specific areas and they provide reliable information on the tested person.
Test module DDT: This is a dichotic listening test. During the test, pairs of sounds are presented to each ear and the task of the tested subjects is to repeat what they heard in one or both ears.
Test module FPT: This is a frequency patterns test. The test items are sequences of three tone bursts that are presented to one or both ears. In each of the sequences two tone bursts are of the same frequency, while the third tone is of a different frequency. There are just two different frequencies used in this test: one is a high-frequency sound and the other a low-frequency sound frequency patterns test.
Test module DPT: This is a duration patterns test. Test consist of sequences of three tones, one of which differs from the other two in the sequences by being either longer or shorter.
Test module GIN: This test allows assessment of the potential of perception of gaps in noise. During the test, the noise is presented with constantly emerging gaps of varying lengths.
System of Integrated Communication Operations „SZOK”®
Every large-scale project involving children or adults, is a great opportunity for early detection of congenital or acquired defects. In response to social needs related to the early detection of birth defects and acquired by detection and prevention, the Institute of Physiology and Hearing Pathology was involved in the implementation of the project, which was named System of Integrated Communication Operations „SZOK”®.
The project's innovation is the use of a system to assist patients with remote diagnosis and to transfer the results of their research to the health services sector. Use of a system to assist patients with remote diagnosis and to transfer audiological screening results to the Institute of Physiology and Pathology of Hearing in Kajetany. Integrating patient data into the "SZOK" ® system, will allow for quick service and thus shorten patient waiting times for visits to IFPS or other specialized facilities and as a comprehensive patient medical base. It is a unique solution in the field of telemedicine and e-health.
Schema of hearing screening protocol
First procedure is videootoscopy. This test is the most accurate visual method examine structure of the outer ear. Examination to check for and diagnose changes in the outer and middle ear between such as earwax, acute or chronic otitis media (with effusion), changes in the fungal infection and tympanic membrane. Examination of the eardrum and ear canal is essential in all ear and hearing health assessments. Digital still images and videos will be recorded during testing child at school and transmitted to the Institute Physiology and Pathology of Hearing for assessment by specialists. Live video consultations have been incorporated into a telehealth service and a reduction in waiting times for specialist services has been shown. This procedures is normally performed by audiologist or otolaryngologist only and provides valuable information. It is a procedures that can be carried out by primary care providers in a telehealth setting after appropriate training.
Afterwards, protocol including Pure Tone Audiometry (PTA) using Platform for Sense Organs Screening. This device is fundamental for inexpensive and universal screening in large population of children. The threshold for air conduction in the frequency range of 500 Hz to 8000 Hz were determined. Result greater than 20 dB at any frequencies indicate possible hearing loss. Moreover, via a network connection, an audiometer was controlled remotely by an audiologist. Results of studies on children have been reported.
Mobile Hearing Center
The Institute of Physiology and Pathology of Hearing have a own truck that they are currently using for running a rural hearing health study – called Mobile Hearing Center. Inside, the truck functions as a regular audiology clinic, only on a much smaller scale. The larger of the two booths has a typical audiology setup with Video Otoscopy, They're able to conduct assessment the external and middle ear. The smaller booth is strictly used for testing adults. It may appear to be a small space; however, it is relatively spacious inside for the patient. Currently, we conduct only hearing screening, but in the future, they hope to have internet on the truck, so when they encounter a situation, (e.g., with video otoscopy), they could evaluate the patient remotely. In that case, it would be a combining of two delivery types. Right now, it is a completely contained mobile audiology clinic, delivering the same level of service as you would expect in a brick and mortar clinic, except that they are able to bring hearing care services to the local community.
Educational and training activities of the Institute of Physiology and Pathology of Hearing are addressed to students and different groups of specialists in the fields of hearing, voice, speech and communication disorders, dysfunctions of breathing, balance and recurring infections of the upper airways. These activities are being conducted in collaboration with Polish and foreign research and academic units. Some of the didactic activities are addressed also to patients and their families.
Beneficiaries of the Institute’s educational activities include not only Polish specialists but also, increasingly, specialists from abroad: Europe, Asia, South and North America and Africa.
Educational program bases on the modern methods and forms of education. Courses are conducted both as the stationary studies and as the distance learning (e-learning). The Institute has two high-technology teleconferencing studios that are used for all types of educational activities. An important factor contributing to the high efficacy of the educational process is a modern didactic base of the Institute that includes 7 conference rooms with 800 places, the only in Poland – 2 multimedia studios of telemedicine and a spacious exhibition area. All rooms are furnished with modern audiovisual equipment and systems for transmission of sound and picture between conference rooms and to the internet.
A unique function is the possibility of transmitting the 3D picture from the surgery room to conference rooms. Surgery room has also an audiovisual connection with the state of the art surgical laboratory, enabling course participants to observe the maneuvers of the instructor demonstrating surgical techniques while performing the same procedures on temporal bones.
Window Approach Workshop
Window Approach Workshop –is a specialized, international training workshops on the field of otorrhaging of implantable devices, in the method of partial treatment of deafness by means of cochlear implants.
This extremely popular training series is addressed to oto-surgeons and audiologists from all over the world who want to broaden their knowledge and skills in the field of hearing aids. Particular attention is paid to the use of hearing aids in the treatment of partial deafness according to the method developed and disseminated by Prof. Henryk Skarżyński - the precursor and creator of Partial Deafness Treatment (PDT).
The Window Approach Workshop (WAW) has been organized since 2007 by the Institute of Sensory organs and the World Hearing Center of the Institute of Physiology and Pathology of Hearing in Kajetany. Up to now, the twentieth edition of the WAW workshop has included 2029 oth- ers from 40 countries (Austria, Azerbaijan, Belgium, Belarus, Czech Republic, Denmark, Democratic Republic of Congo, Egypt, France, Greece, Iraq, Cameroon, Kenya, Hungary, Italy, Turkey, Romania, Turkey, Ukraine).
The most important issue learned and practiced during the workshop is implantation of the cochlear implant electrode in a minimally invasive way through the rounded auger window, which allows for the maintenance of hearing remains and intact anatomical structures. This method was developed and developed by Prof. Henryk Skarżyński at the Institute of Physiology and Pathology of Hearing.
An exceptional element of WAW workshops, particularly attractive for surgeons, is the demonstration operations conducted by Prof. Henryk Skarżyński and IFPS Department of Otolaryngology Surgery. Such demonstration operations are a very important part of surgeon training. They enable the observation of the work of an experienced operator, the organization of the entire surgical team and the equipment of the operating room. Many of these observed, proven solutions are later deployed in operating rooms around the world.
The program of the Window Approach Workshop includes:
• Lectures presented by the specialists from the Institute of Physiology and Pathology of Hearing,
• Demonstration surgeries transmitted from the operating theater to the lecture room, with presentation of each case and discussion,
• Hands - on training in the laboratory on fresh temporal bone specimens.
LION Global Otology – Neurotology Live Surgical Broadcast
The LION project, launched in 2006, is dedicated to using the latest teleconferencing technologies for the continuing training of otolaryngologists around the world. Within LION there is a permanent interactive world-wide training network that provides direct access to the knowledge and experience of international otology and neurologist experts to every doctor who has a computer and access to the internet. The key component of this program is annual video conferencing with oto-surgeons representing leading centers around the world.