You have accessSIG 18 TelepracticeViewpoint5 Apr 2023

Viewpoint Telepractice 2025: Exploring Telepractice Service Delivery During COVID-19 and Beyond

    Abstract

    Purpose:

    The purpose of this article is to outline the challenges and opportunities faced by speech-language pathologists (SLPs) providing telepractice services as the profession approaches the 100th anniversary of the American Speech-Language-Hearing Association in 2025. As this anniversary approaches, SLPs nationwide will reflect on the profession's past, present, and future. Undoubtedly, issues concerning the COVID-19 pandemic and the use of telepractice technology during this time will be analyzed. This article will outline several challenges for the profession and clinicians to consider for the longevity of telepractice service delivery, including (a) consensus on eHelper/facilitator terminology, (b) designating a telepractice service delivery model, (c) exploring telepractice occupational culture, and (d) pursuing future directions (e.g., ethnographic applications and cultural-linguistic diversity).

    Conclusions:

    Although telepractice service delivery has existed for less than a century, there is evidence of rapid progress. Meeting the challenges ahead for SLPs using telepractice may have a lasting impact on clinical implications in the field of speech-language pathology in 2025 and beyond the COVID-19 pandemic.

    In 2025, the American Speech-Language-Hearing Association (ASHA) will celebrate its 100th anniversary. Communication Sciences and Disorders and the professional field of speech-language pathology will meet a milestone that will bring high expectations for the future. When rising to the challenge of integrating telepractice technology while working at the top of the professional license, speech-language pathologists (SLPs) must consider various service delivery options to maximize time with clients (ASHA, 2018). As telepractice service delivery continues to evolve, further challenges and opportunities faced by practicing clinicians will be revealed. However, several challenges are already clear and current milestones for telepractice service delivery during the COVID-19 pandemic, such as reimbursement, licensure, and workload/caseload (Kwok et al., 2022; Warren, 2022). While these issues represent the much-needed direction as to the future course of telepractice, several issues existed and persisted before the COVID-19 public health emergency, and consensus on these issues can shape the direction of telepractice into the next decade (Kollia & Tsiamtsiouris, 2021; Kwok et al., 2022).

    As part of this expectation to meet and exceed professional standards during challenging times before, during, and after the COVID-19 pandemic, SLPs should consider (a) reaching a consensus on eHelper/facilitator terminology, (b) designating a telepractice service delivery model, (c) exploring telepractice occupational culture, and (d) pursuing future directions (e.g., ethnographic applications and cultural-linguistic diversity). These issues represent the strengths and challenges ahead for SLPs and telepractice technology, and meeting these challenges may have a lasting impact on clinical implications in the field of speech-language pathology in 2025 for the 100th ASHA anniversary and beyond.

    Consensus on eHelper/Facilitator Terminology

    At the time of this publication, there is not a universally accepted title for the individual who assists the SLP in a telepractice setting and the terms “eHelper” and “facilitator” are used interchangeably in telepractice literature in speech-language pathology (Alvares, 2013; Edwards-Gaither, 2020; Kwok et al., 2022; Overby, 2018). The ASHA (n.d.) guidelines on telepractice key issues provided the following information for a “facilitator” in telepractice:

    Appropriately trained individuals may be present at the remote site to assist the client. Unless restricted by institutional or state policies or regulations, the facilitator may be a teacher's aide, nursing assistant, client clinician, audiology assistant or speech-language pathology assistant, teleaudiology clinician technician, telepresenter, or other type of support personnel, interpreter, family member or caregiver, among others. (para. 3)

    To come to a consensus of the use of terminology between “eHelper” or “facilitator” in telepractice services, the information needed may come from other professions. One such source could be the American Telemedicine Association (ATA). The ATA (n.d.) is a coalition and partnership of over 400 organizations dedicated to the “adoption of telehealth and virtual care, promote responsible policy, advocate for government and market normalization, and provide education and resources to help integrate virtual care into emerging value-based delivery models” (para. 1).

    In 2017, ATA voted for the accreditation of a telehealth training program that offers a Telehealth Facilitator certificate, overseen by Thomas Jefferson University in Pennsylvania. Successful completion of the 5-week program culminates in the individual earning a Telehealth Facilitator certificate. The holder of the Telehealth Facilitator certificate is then recognized as an individual who will (a) facilitate conversation between patient and provider; (b) initiate the encounter, manage the interface between doctor and patient, and address all technical challenges that may arise; and (c) ensure a sound and successful, professional medico-legal and culturally sensitive experience for the patient (Thomas Jefferson University, n.d., para. 5).

    Along with the clearly defined roles and responsibilities as outlined above, the title of Telehealth Facilitator is accepted within the body of professionals represented by ATA. The Telehealth Facilitator role outlined by ATA could be a model used by ASHA and accepted by SLPs. The role of the eHelper/facilitator is a prominent contributor in telepractice and an asset to the SLP with regard to assisting and facilitating sessions (Edwards-Gaither, 2020) and their usefulness in school-based intervention (Alvares, 2013). However, without consistent nomenclature, professionals are left without clear guidance on the role or the title. If the terminology “facilitator” or “eHelper” were to be accepted broadly and utilized consistently, this could be another step in best practices in telepractice and the field of speech-language pathology.

    A Need for a Recognized Telepractice Service Delivery Model

    The interactions between humans and technology must be considered when investigating telepractice and the social context of the individuals who work in the telepractice setting. When telepractice services are provided in speech-language pathology, the SLP depends on technology (the Internet, videoconferencing, hardware, and software) to connect to the client. The social construction of technology theory (SCOT; Pinch & Bijker, 1984) is a theoretical approach to technological development and application that can be applied to telepractice in the field of speech-language pathology. In the broadest sense, the proponents of SCOT argue that humans attach meanings or interpretations to artifacts, and people and social groups direct technological development through these meanings and interpretations (Brundisini, 2018). The origins of SCOT are attributed to Pinch and Bijker (1984), who described how social groups and technical artifacts interact.

    A social construction of telepractice (SCOTele) model is a novel model for communication disorders and speech-language pathology (see Figure 1). For the model to be adopted, additional studies connecting the SCOT theory with speech-language pathology and, therefore, telepractice are necessary. In addition, precedence has been set for applying the SCOT theory in allied health and health professions, including telemedicine. Brundisini (2018) investigated the social construction of telemedicine within a social group (users in Ontario, Canada) and the role it played in the health care system. Through the analysis of newspaper articles, websites, and interviews with telemedicine stakeholders spanning over 20 years, results indicated a multilayered view from stakeholders (physicians/providers, consumers, and policymakers) of the impact of telemedicine on the clinicians and the clients (Brundisini, 2018).

    Figure 1.

    Figure 1. A model of the social construction of telepractice (SCOTele). SLP = speech-language pathologist.

    A Model of the SCOTele

    These findings ring true for the historical arch of telepractice in speech-language pathology. While early adopters may have had high hopes of a telepractice revolution, the adoption of telepractice may have been steady but slower than expected until the COVID-19 pandemic ushered in rapid adoption (Kollia & Tsiamtsiouris, 2021). Looking toward 2025 and beyond, a contemporary study of SCOT and telepractice in speech-language pathology may help create a new and modern vision of telepractice that accommodates the user (SLPs and eHelpers/facilitators), the consumer (students, clients, patients, and caregivers), and policymakers (ASHA and federal agencies), consequently framing the future of telepractice reimbursement, licensure, challenges, and opportunities to come.

    Exploration of Occupational Culture and Telepractice

    Occupational culture is composed of the interconnections between people, technology, occupation, behaviors, and processes. Cabrera et al. (2001) asserted that new technology influences an organization's culture, so that users within the culture are required to change their behaviors to comply with the technology. The ability of a new technology to be infused into a culture depends on whether the technology is well suited for the culture and whether the culture is adaptable to the changes in behavior required to implement the technology (Cabrera et al., 2001; Walker & Whetton, 2002).

    SLPs must adapt their traditional service model used in the in-person setting when using videoconferencing platforms and software during telepractice sessions. As communication experts, SLPs are accustomed to having direct eye contact with their clients, providing reinforcement to elicit responses, and using behavior management techniques to ensure the client is engaged in activities to make progress. Traditional professional practices must be adapted or changed to provide telepractice services when the SLP is physically separated from the client and relying upon videoconferencing technology. Thus, the occupational culture of speech-language pathology must also adapt when technology is introduced.

    Videoconferencing platforms were built for occupational cultures, including private, for-profit entities, and academia. Understanding the cultural factors that influence the usage and perception of communication via the Internet and videoconferencing is essential to researchers in communication sciences and disorders, instructional designers, and engineers of current and future technologies. When these factors are understood, professional technological adaptations such as telepractice can be considered to meet the needs of the SLP, the eHelper/facilitator, and the client.

    Future Directions

    Applications of SCOT for Telepractice (SCOTele)

    An in-depth look at social constructivism theory and social constructivism (Pinch & Bijker, 1984) as it applies to communication sciences and disorders and those who utilize telepractice as the primary modality to provide services would benefit the field. The clinical and professional applications of SCOTele are vast when considering research combining communication sciences and disorders and technology (Leader, 2020). The more significant challenge is determining where to begin such research and what components to include. At this time, speech-language pathology relies on videoconferencing platforms and products designed for other industries (mainly businesses and corporations) and adapts the therapeutic model of services to fit a system not designed for the clients or the profession. When applying the social-constructivist theory, a videoconferencing platform could be designed to capture or include interpersonal features, nonverbal features, eye contact, behavioral modification, or even reinforcement. Additional applications of SCOTele could provide considerable value for future directions of telepractice, including applying this knowledge to how clients and clinicians experience telepractice for improved service delivery (Leader, 2020).

    Ethnography of Telepractice

    Future studies of telepractice in speech-language pathology could utilize an ethnographic approach to the SLP's experience with telepractice. Ethnographic techniques are deeply rooted in anthropology and the study of human societies, cultures, and development (Hymes, 1974). When first proposed, the ethnography of communication was considered a novel approach for researching language with the focus placed on the linguistic practices of sociocultural groups and attention given to matters of context (Kalou & Sadler-Smith, 2015). Ethnographic studies of the client's perspective and contributions to telepractice could provide needed clinical insights, especially regarding clients diagnosed with autism spectrum disorder or with social-pragmatic deficits. Using ethnographic techniques, the investigator can observe interactions and language use within the context of the culture (Ferrari & Bundesen, 2017). Ethnographic inquiry into telepractice is needed, which is practiced mainly in an untraditional online context where the SLP is physically and geographically separated from the client. Examining telepractice utilizing ethnographic techniques would provide much-needed information about communication in the online environment and informed best practices in the profession of speech-language pathology.

    Cultural-Linguistic Diversity

    Another future direction of telepractice related to the 2025 100th anniversary of ASHA is the growing diversity of the United States, which is predicted to increase the diversity of telepractice caseloads (Edwards-Gaither, 2018). Possible applications of such diversification in the client population could include an investigation of the eHelper/facilitator as a cultural mediator or as an interpreter for a bilingual client. Again, the ethnographic model of observations and interviews could reveal if or how the interactions between the SLP, client, and eHelper/facilitator occur via telepractice. In the ATA Telehealth Facilitator Certificate curriculum (Thomas Jefferson University, n.d.), cultural sensitivity training is provided within the program. In this paradigm, the eHelper/facilitator's interactions with clients could be examined and summarized for a new look at how technology, culture, and communication intersect in a therapeutic environment. Furthermore, according to ASHA (n.d.), adequate training of a telepractice facilitator includes “knowledge of and sensitivity to clients' cultural and linguistic differences, as well as how such differences may influence participation in telepractice” (para. 2). The use of technology and telepractice to reach culturally and linguistically diverse clients has been established. Therefore, SLPs should be prepared to handle the challenges and related issues (cultural awareness, cultural humility, and dialects) in order to provide high-quality services to all clients.

    Post–COVID-19 Applications

    The COVID-19 pandemic is currently an active and present part of society, changing the landscape of client care and presenting an emerging paradigm shift from in-person services to online remote services (Kollia & Tsiamtsiouris, 2021). In the brief period of March 2020 through June 2020, COVID-19 ushered in a rapid and sweeping adoption of virtual services in several industries, including telehealth, telemedicine, ecounseling, and eLearning (Tenforde et al., 2020). This expansion included speech-language pathology services via telepractice, which ensured that clients received services while reducing the risk of transmitting COVID-19 from clinician to client and vice versa. The rapid adoption of these guidelines created a window of opportunity to educate telepractice adopters, stakeholders, clinicians, and decision makers on the necessity of telepractice services. As clinicians rushed to learn, adopt, and integrate telepractice services into their respective caseloads, the lack of consensus on terminology, licensure, and even reimbursement issues came to light, and the complexities of establishing a telepractice program were revealed. The telepractice service delivery model consists of much more than acquiring the equipment and hardware; it also involves the human aspects of clinician-client relationships. Future studies could provide a clearer picture of the impact of COVID-19 on telepractice services and the impact rapid adoption may have on the retention and sustainability of these services.

    Conclusions

    Telepractice is broadly defined as the use of information and communication technology to deliver speech-language pathology services at a distance (ASHA, n.d.). Based on this definition, the key components are assumed to be the Internet, the hardware, and software involved in the connection. Alternatively, from a clinical standpoint, telepractice is a tool that connects SLPs with clients when they are in need of services and when a clinician may not be available in their area (ASHA, n.d.). Telepractice service delivery includes a complex set of undefined guidelines and human elements, including the Internet, hardware, software, clinician, client, and the eHelper/facilitator.

    Within the pre– and post–COVID-19 landscape of increased use of online, remote services to meet the Center for Disease Control safety standards (ASHA, 2020), there is ample opportunity for telepractice to become a more mainstream modality of service beyond 2025. During the height of the pandemic, when online services were the only option for many clients, telepractice sessions continued to lack elements of consensus in literature, practice, and key stakeholders in regard to terminology, occupational culture, and ethnographic research opportunities, which, if established, can help shape future use. There is a clear and present opportunity within the community of communication sciences disorders scholars, telepractice experts, and decision makers to shape telepractice guidelines in the future. In the United States, the post–COVID-19 rush to implement telepractice indicated a clear need to transition to a responsive service delivery model, and the fast pace of this transition was evident. This distinct paradigm shift and increased interest may catapult telepractice into a mainstream service delivery model in the near future.

    At the time of this article, a scarce amount of literature addresses how telepractice ties into theoretical models of technology use in speech-language pathology (SCOTele). Drawing from the social construction of technologies framework, the shared understanding of what telepractice is and is not and what the varied elements of an online teletherapeutic setting can be explored. Accordingly, it can be concluded that to truly understand telepractice, one must first start by focusing on the user of the technology, as evidenced in ethnographic research approaches. To date, the literature on telepractice focuses on the much-needed evidence of the efficacy of telepractice with clients and the SLP's perceptions of telepractice. Therefore, it is suggested that, in future studies, the focus may be on the user of the technology (SLP, client, and eHelper/facilitator) to understand the technology entirely.

    This article was written to provide insight into telepractice based on the opportunities ahead in light of the COVID-19 pandemic and beyond the ASHA 100th anniversary. These issues and topics related to the future application of telepractice technology will contribute to the larger body of research used to prioritize and legitimize telepractice as a mainstream service modality. The future of telepractice includes and requires a consensus on terminology for clarity of communication clarity within and outside our field, a recognized telepractice service delivery model (SCOTele), an examination of occupational culture, and the pursuit of future directions including cultural-linguistic diversity. As the field of speech-language pathology moves into a post–COVID-19 paradigm of online services, it is clear that telepractice will become a more permanent part of the clinical landscape. In 2025, and upon ASHA's 100th anniversary, the profession of speech-language pathology will inevitably continue to balance communication and technology to improve the basic human need to communicate.

    Data Availability Statement

    Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

    Acknowledgments

    The authors would like to acknowledge Kay Payne and Linda Bland Stewart for their support and expertise.

    References

    Author Notes

    Disclosure: Lesley Edwards-Gaither is the coauthor of Telepractice: A Clinical Guide for Speech-Language Pathologists. Lesley Edwards-Gaither is the CE Manager for SIG 18 Telepractice. The authors have declared that no other competing financial or nonfinancial interests existed at the time of publication.

    Correspondence to Lesley Edwards-Gaither:

    Editor-in-Chief: Celeste Domsch

    Editor: Geralyn M. Schulz

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