Roles and Responsibilities

Roles and responsibilities for audiologists and speech-language pathologists (SLPs) in the provision of services via telepractice include

• understanding and applying appropriate models of technology used to deliver services;
• understanding and troubleshooting the appropriate specifications, security, and operations of technology used in the delivery of services;
• calibrating and maintaining clinical instruments and telehealth equipment;
• selecting clients who are appropriate for assessment and intervention services via telepractice;
• selecting and using assessments and interventions that are appropriate and valid to the technology being used and that take into consideration client needs;
• being sensitive to cultural and linguistic variables that affect the identification, assessment, treatment, and management of communication disorders/differences in individuals receiving services via telepractice;
• training and using support personnel and extenders (e.g., rehab technicians, family members, community workers, and speech-language pathology assistants and audiology assistants) appropriately when delivering services;
• being familiar with the available tools and methods and applying them to evaluate the effectiveness of services provided and to measure outcomes;
• maintaining appropriate documentation, including informed consent for use of telepractice and documentation of the telepractice encounter;
• being knowledgeable about and compliant with existing rules and regulations regarding telepractice, including security and privacy protections; reimbursement for services; and licensure, liability, and malpractice concerns; and
• collaborating with medical, educational, and community sources for timely referral and follow-up services.

Ongoing education and training are required to maintain expertise and familiarity with changes in technology and potential clinical applications (Towey, 2012a).

ASHA requires that individuals who provide telepractice abide by the ASHA Code of Ethics (ASHA, 2023). Also, see papers by Cohn and Cason (2019), Denton and Gladstone (2005), and Meline and Mata-Pistokache (2003) for further information.

Licensure and Teacher Certification

States may have legal or regulatory requirements regarding telepractice. Clinicians verify state licensure requirements and policies in the state from which the clinician provides services and the state in which the client receives services prior to initiating services. Clinicians should also verify requirements including temporary location changes such as vacations and college attendance.

Current guidance in medical and legal practices indicates that the client’s location is the originating site (i.e., site of service) and the provider’s location is considered the distant site. ASHA guidelines assert that telepractitioners must be licensed in both the state from which they provide services and the state where the client is located at the time of service. ASHA, along with its state regional organizations, has now established the Audiology & Speech-Language Pathology Interstate Compact (ASLP-IC). The ASLP-IC is intended to allow professionals to practice in multiple states without having to obtain additional state licenses. For updates on the compact, please see ASHA’s resource on Audiology & Speech-Language Pathology Interstate Compact (ASLP-IC) and the ASLP-IC website.

Civilian employees of the Department of Defense and the Department of Veterans Affairs may not be bound by the same licensing requirements. Confirm the specific licensing requirements for your circumstances.

Clinicians planning to do telepractice in a school setting in a state other than where they reside should communicate with the Department of Education and the licensure board (in the state where service is provided) to determine whether licensure and/or teacher certification is required and to obtain further guidance as appropriate.

See ASHA’s state telepractice and telesupervision requirements (select your state for detailed information).

International Considerations

ASHA-certified audiologists and SLPs who deliver telepractice services to individuals in other countries are bound by ASHA’s Code of Ethics (ASHA, 2023), Scope of Practice in Audiology (ASHA, 2018), Scope of Practice in Speech-Language Pathology (ASHA, 2016), Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006), and Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 2004).

Prior to providing international telepractice services, it is important to

• confirm requirements, if they exist, for the practice of audiology or speech-language pathology in specific countries (see ASHA’s resource on Audiology and Speech-Language Pathology Associations Outside of the United States for a list of international associations) and
• consult additional resources on providing services with cultural and linguistic sensitivity (see ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness).

ASHA recommends that practitioners check their professional liability status and consult with the regulatory body in that country.

Reimbursement

Historically, coverage and payment of telepractice services varies widely across federal, state, and commercial payers (e.g., Medicare, Medicaid, private health insurance). During the COVID-19 Public Health Emergency, temporary policies and exceptions were implemented to increase access to telepractice services. Some telepractice models (e.g., remote patient monitoring) may not be reimbursable by current coverage and payment standards. It is critical for clinicians to verify telepractice coverage and billing guidelines by the client’s payer before initiation of services. See Payment and Coverage of Telepractice Services: Considerations for Audiologists and Speech-Language Pathologists for detailed coding, Medicare, Medicaid, and commercial insurance information.

Telepractice providers should be prepared to educate payers about how telepractice services are delivered and the benefits to clients and payers. Educational materials may include research articles, organization policies and procedures to ensure provider training and quality services, educational/informed consent materials for clients, video clips, and testimonials.

See the ASHA State-by-State page for further details.

Client Selection

Telepractice may not be appropriate in all circumstances or for all clients. Consider each client’s familiarity/experience with telepractice/technology, the availability of Internet/technology/support, each client’s desire to use telepractice and ability to interact/engage via telepractice, and any other relevant items. Clinicians may explore the benefits and challenges of other service delivery models before initiating telepractice services. Telepractice may be used for a trial period to confirm whether it is an appropriate service delivery model. Training and/or consultation via telepractice may be provided to the client’s family/caregivers or to other health care providers, as appropriate, for clients who are either unable to interact/engage via telepractice or not benefiting from services via telepractice. However, such services may not be reimbursable in the absence of the patient.

Clinicians assist in determining eligibility for services and making progress toward goals via telepractice. Additional supports such as use of an interpreter; captioning; other online tools; and/or collaboration with family, caregivers, and facilitators may be appropriate for improving telepractice interactions and client outcomes.

The potential for telehealth to create new burdens for the client and caregivers should be considered and discussed during the decision-making process. The specific telehealth model may require the client and/or caregivers to assume responsibility for managing technology, gathering therapeutic materials, and assisting in the execution of specific therapeutic techniques. Ramifications of shifting care from the clinic or school to the client or family must be included in the client selection process (May et al., 2014).

Client characteristics that may potentially impact their ability to interact or engage via telepractice include the following:

• Physical and sensory characteristics, including
  • hearing ability,
  • visual ability (e.g., ability to see material on a computer monitor),
  • manual dexterity (e.g., ability to operate a keyboard if needed), and
  • physical endurance (e.g., sitting tolerance)
• Cognitive, behavioral, and/or motivational characteristics, including
  • level of cognitive functioning,
  • ability to maintain attention,
  • ability to sit in front of a camera and minimize extraneous movements to avoid compromising the image resolution, and
  • willingness of the client and family/caregiver (as appropriate) to receive or assist with services via telepractice
• Communication characteristics, including
  • auditory comprehension;
  • literacy;
  • speech intelligibility; and
  • availability of an interpreter, if needed
• Client’s access to support resources, including
  • availability of technology (e.g., computer, adequate bandwidth, webcam);
  • availability of support personnel (e.g., telepresenter, eHelper, caregiver, facilitator), if needed; and
  • an appropriate environment for telepractice (e.g., quiet room with minimal distractions)
• Other considerations, such as
  • ability and willingness of the client, caregiver, and/or facilitator to follow directions to participate in the session, assist the clinician as directed, and operate and troubleshoot telepractice technology and transmission, if needed;
  • ability and willingness of the client, caregiver, and/or facilitator to participate in the session and assist the clinician as directed; and
  • potential shift of burden to the client due to telepractice implementation

Environmental Modifications and Considerations

Clinicians should pay deliberate attention to the physical and interpersonal aspects of a telepractice encounter. Advance planning and preparation are needed for optimal positioning of the client, test materials, and therapy materials and for placement of the video monitor and camera (Duane et al., 2021; Jarvis-Selinger et al., 2008).

Modifications to in-person verbal and nonverbal communication strategies may be needed to provide optimal service and to establish and maintain the client–provider relationship.

• Visual modifications may include positioning the camera to provide a passport view of the provider and angling the provider’s camera to simulate eye contact.
• Verbal modifications may include using a slower speech rate, increased pausing, and emphasizing suprasegmental features.
• Nonverbal modifications may include exaggerated facial and hand gestures.

Captioning should be considered for all patients regardless of hearing status, so they do not have to rely on verbal information or visual information alone.

Attention to environmental elements is important to ensure the comfort, safety, confidentiality, and privacy of clients during telepractice encounters. Careful selection of room location, design, lighting, and furniture should be made to optimize the quality of video and audio data transmission and to minimize ambient noise and visual distractions in all participating sites. The clinician’s backdrop should be professional and free of clutter. A neutral background in shades of blue or gray improves appearance.

Practice Areas

The growing body of research on the use of telepractice for communication disorders includes many studies demonstrating the comparability of telepractice and in-person services. Please see ASHA’s Telepractice Evidence Map for further information.

Audiology

Computer-based clinical applications are common in audiology practice (Choi et al., 2007; Kokesh et al., 2009). Audiologists frequently use computer peripherals—such as audiometers; hearing aid systems; and auditory brainstem response, otoacoustic emission, and immittance testing equipment—that can be used in telepractice. Hearing instrument, cochlear implant, and audiologic equipment manufacturers are now promoting equipment with synchronous or store-and-forward capabilities.

Audiologists have used telepractice to provide audiological services, including, but not limited to, the following:

• Aural rehabilitation (Bush et al., 2016; Polovoy, 2009; Saunders & Chisolm, 2015; Yates & Campbell, 2005)
• Cochlear implant fitting (Bush et al., 2016; Eikelboom et al., 2014; Hughes et al., 2012; Kuzovkov et al., 2014; McElveen et al., 2010; Wasowski et al., 2012)
• Family-centered pediatric interventions for deaf or hard of hearing children (McCarthy et al., 2019)
• Hearing aid fitting and use (Bush et al., 2016; Campos & Ferrari, 2012; Muñoz et al., 2017; Paglialonga et al., 2018; Penteado et al., 2012, 2014; Pross et al., 2016; Tao et al., 2018)
• Infant and pediatric hearing screenings (Botasso et al., 2015; Krum, Huffman, et al., 2007; Krumm, Ribera, & Klich, 2007; Krumm et al., 2005; Lancaster et al., 2008; Skarzyński et al., 2016; Stuart, 2016)
• Hearing conservation programs to manage occupational noise-induced hearing loss (Khoza-Shangase & Moroe, 2020)
• Other hearing screening and assessment procedures, such as auditory brainstem response, immittance, and otoacoustic emission testing (Molini-Avejonas et al., 2015)
• Pure-tone audiometry (Masalski & Kręciki, 2013; Molini-Avejonas et al., 2015; Swanepoel et al., 2010; Visagie et al., 2015)
• Sign language use (Donne, 2013)
• Speech-in-noise testing (Molini-Avejonas et al., 2015; Ribera, 2005)
• Tinnitus treatment (Beukes et al., 2019; Nagaraj & Prabhu, 2020)
• Vestibular disorder treatment (Beukes et al., 2019)
• Video otoscopy (Biagio et al., 2013, 2014; Eikelboom et al., 2002; Kokesh et al., 2008; Lancaster et al., 2008)
• Probe microphone hearing aid measurements (Ferrari & Bernardez-Braga, 2009)
• Cochlear implant telemetry (Shapiro et al., 2008)

Speech-Language Pathology

SLPs use telepractice to assess and treat various disorders, including, but not limited to, the following:

• Acquired brain injury (Coleman et al., 2015)
• Aphasia (Hall et al., 2013; Kurland et al., 2018; Macoir et al., 2017; Weidner & Lowman, 2020)
• Articulation disorders (Coufal et al., 2018; Crutchley et al., 2010; Grogan-Johnson et al., 2013; Wales et al., 2017)
• Autism (Allen & Shane, 2014; Higgins et al., 2017; Iacono et al., 2016; Parmanto et al., 2013; Sutherland et al., 2018)
• Dysarthria (Hill et al., 2006; Sevitz et al., 2021)
• Dysphagia (Cassel, 2016; Malandraki et al., 2011; Nordio et al., 2018; Perlman & Witthawaskul, 2002; Raatz et al., 2021; Weidner & Lowman, 2020)
• Fluency disorders (Carey et al., 2012, 2014; Lewis et al., 2008; McGill et al., 2019; Tomaiuoli et al., 2021)
• Language and cognitive disorders (Brennan et al., 2004; Carlew et al., 2020; Manning et al., 2020; Musaji et al., 2021; Sekhon et al., 2020; Sutherland et al., 2016; Waite et al., 2010)
• Neurodevelopmental disabilities (Simacek et al., 2017)
• Parkinson’s disease (Weidner & Lowman, 2020)
• Traumatic brain injury (Weidner & Lowman, 2020)
• Voice disorders (Doarn et al., 2019; Halpern et al., 2012; Mashima & Brown, 2011; Rangarathnam et al., 2016; Theodoros et al., 2006; Tindall et al., 2008; Towey, 2012b)

Modification of Assessment and Treatment Techniques and Materials

Clinicians who deliver telepractice services must possess specialized knowledge and skills in selecting assessments and interventions that are appropriate and valid when administered remotely. This decision must also take into consideration factors related to each individual client and disorder variables. Assessment and therapy procedures and materials may need to be modified or adapted to accommodate the lack of physical contact with the client. These modifications must be made transparent when interpreting and documenting services provided. Publisher permission is necessary to modify assessment materials in any way and may be provided on a case-by-case basis. Please check with the publisher before modifying assessment materials. Please see Considerations for Speech, Language, and Cognitive Assessment via Telepractice for further information.

Some publishers of standardized assessments have developed guidance about the administration of tests via telepractice or validated assessments for administration via telepractice. Other researchers have compared the validity of in-person and remote assessment protocols (Sutherland et al., 2016; Taylor et al., 2014; Thai-Van et al., 2020; Weidner & Lowman, 2020).

School Setting Considerations

Telepractice services may be provided by private contractors with a local education agency or school district or by audiologists and SLPs employed by the district. The strategic use of telepractice addresses shortages of clinicians in some school districts, increases flexibility to meet workload demands by reducing travel to multiple schools, and improves accessibility to providers. Telepractice affords a more accessible and preferred format of service delivery for some students receiving direct services and assessments as well as for collaborating with staff and families receiving consultative services (Boisvert & Hall, 2019; Grogan-Johnson, 2021).

The effectiveness of telepractice as a service delivery model in the schools is well documented (Gabel et al., 2013; Grogan-Johnson et al., 2010, 2011; Lewis et al., 2008; McCullough, 2001; Sanchez et al., 2019). In addition, parents, clients, and clinicians report satisfaction with telepractice as a mode of service delivery (Crutchley & Campbell, 2010; McCullough, 2001; Rose et al., 2000; Sanchez et al., 2019).

The administrative body responsible for defining telepractice-based services in a school or school district

• ensures that telepractice clinicians (who may not reside in the state where the school is located) meet all state requirements to practice in the school;
• makes certain that telepractice clinicians have knowledge, skills, and training in the use of telepractice;
• recognizes that every student may not be best served by a telepractice model and gives students the opportunity to receive traditional in-person services;
• informs parents that they have the right to decline telepractice services for their child;
• provides parents with an informed consent form, satisfaction survey, or other feedback option;
• provides parents opportunities to discuss concerns about their child’s progress or the telepractice program;
• documents service delivery via telepractice on the individualized education program (IEP) and during IEP meetings;
• creates policies that ensure privacy during service delivery and documentation of the services provided;
• provides on-site support for the telepractice sessions, including the assignment of an individual to accompany the student to the session and provide support during the session; and
• develops a plan to
  • provide in-person services to staff;
  • provide training for on-site facilitators (see the ASHA Facilitator Checklist for Telepractice Services in Audiology and Speech-Language Pathology [PDF]);
  • maintain ongoing contact and collaboration with teachers, parents, and other school personnel—thereby ensuring that state standards are met; and
  • develop a system of program evaluation to measure the effectiveness of the service and satisfaction of the stakeholders.

Some states allow reimbursement for eligible students covered by Medicaid when services are delivered via telepractice; however, the state’s Medicaid policy and coding guidance should be verified. See ASHA State-by-State and Payment and Coverage of Telepractice Services: Considerations for Audiologists and Speech-Language Pathologists for more information.

Telepractice Technology

Specifications and selection of the appropriate hardware and software equipment and connectivity vary according to the telepractice application. Technical support and training in the use of telepractice equipment are essential for success, and these needs will be ongoing as technology continues to evolve.

Videoconferencing Tools (Hardware, Software, and Peripheral Devices)

Video communication may be completed via personal videophones, videoconferencing software, and dedicated videoconferencing hardware and secure web-based programs.

Factors/options in the selection of videoconferencing tools include the following:

• Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance and security of the videoconferencing platform
• Camera capabilities (e.g., pan–tilt–zoom and resolution); display monitor capabilities (e.g., size, resolution, touch screen, and dual display); microphone and speaker quality; and multisite capability, a way to allow clinicians to access data and provide services from two or more separate work environments
• Peripheral devices, such as recording devices or auxiliary video input equipment for computer interfacing, document cameras, or other specialized cameras with high resolution (e.g., fiberoptic videoendoscopes, dental cameras)
• Additional modes of real-time interaction through applications, including, but not limited to
  • screen sharing,
  • captioning,
  • annotation,
  • whiteboards,
  • online presentation without limitations,
  • text chat,
  • recording (with or without editing capability), and
  • interactivity features (e.g., animations, widgets, games, stamps, and paintbrush).

Considerations in Selecting a Web Conferencing Collaboration Service

There are three web conferencing option levels—business class, software-based, and public domain.

• Business class—involves the purchase of hardware and is typically used at large facilities such as universities or medical centers
• Software-based—provides information on the level of encryption and includes an agreement with the practitioner on how the client’s information is protected
• Public domain—is not validated as secure and often does not indicate how information is encrypted (e.g., FaceTime, Skype, and Google Hangouts)

When selecting a web conferencing option,

• review full product description, subscription details, and pricing;
• note the required processing speed and needed storage capacity of the device to be used;
• evaluate the ease of use to (a) host an encounter and (b) join an encounter (e.g., a software download or a specific web browser that is required to join a meeting);
• consider compatibility and functionality across device types (e.g., smartphone, tablet, computer) and operating systems (e.g., PC, iOS, Android);
• request a trial period to experience features, functionality, limitations, and challenges;
• consider scalability (number of hosts and attendees permitted);
• research the forms (e.g., phone, chat, tutorials) and responsiveness of tech support and active user communities;
• determine whether there is an international limitation if dial-in numbers are needed to join the encounter; and
• review privacy/security features and, if applicable, determine HIPAA compliance.

Connectivity

During telepractice, information is transmitted across a telecommunications connection (e.g., point-to-point, dedicated line, web-based) between individuals at different sites.

Consider the following factors in determining an appropriate connection strategy:

• Network connection speed affects the overall quality of video and audio clarity. An upload/download speed of no less than 3 MB is needed for optimal connection and screen sharing. When adding a shared video source (e.g., Microsoft PowerPoint, YouTube, or video recordings), upload and download speeds should be no less than 5 MB.
• Available bandwidth may be reduced by the number of software applications running on the computer and/or the number of users on the communication network, for example, during peak usage times in schools.
• Higher connection speeds may be required for a high-definition, dual-streaming video presentation or for hosting multipoint calls. Lower bandwidth may result in delays, jitter, and loss of data and may interfere with the quality of signals for clinical decision making or normal turn-taking in conversational discourse.
• Establishing an alternative connection (e.g., telephone, e-mail) enables participants to troubleshoot connection problems or to reschedule the session.
• Lack of technological compatibility may be a barrier to connecting sites with different hardware, software, and bandwidth speeds. A hard-wired connection is optimal in a shared Wi-Fi environment.
• Secure transmission during telepractice may be obtained through the use of encryption, unique passwords, unique meeting numbers, secure connection via a virtual private network (VPN), and hardware/software firewalls.
• Store-and-forward or asynchronous telepractice, in which data are collected at one site and sent to another site at a different time, may be useful in cases of low Internet bandwidth or in situations with no Internet connection.

Facilitators and Interpreters in Telepractice for Audiology and Speech-Language Services

In telepractice, a facilitator is an individual who is present at the client site to support the client and the remote clinician. The specific duties of facilitators depend on the service being provided (Coco et al., 2020). Duties may include assisting the client with hands-on tasks, helping manage local equipment/technology, monitoring client participation and safety, and supporting the remote clinician with on-site tasks (e.g., providing copies of documentation).

Unless restricted by institutional or state policies or regulations, any appropriately trained individual may act as a facilitator. The facilitator may be a teacher’s aide, a student clinician, an audiology assistant or a speech-language pathology assistant, a teleaudiology clinical technician, a licensed health care professional, an interpreter, other support personnel, or a family member/caregiver, as appropriate and as available. It is not preferable to have a family member act as both facilitator and interpreter in instances when interpretation is required. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators for further details.

It is the responsibility of the practitioner to direct the session and ensure that the facilitator is adequately trained to assist. Douglass et al. (2021) published a study proposing minimum competencies for tele-facilitators in the school setting. Adequate training includes knowledge of and sensitivity to clients’ cultural and linguistic differences as well as how such differences may influence participation in telepractice (see ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Cultural Responsiveness).

Practitioners must be aware of applicable federal and state policies and regulations including privacy issues (e.g., HIPAA) and reimbursement allowances regarding the use of facilitators. Please see the ASHA Facilitator Checklist for Telepractice Services in Audiology and Speech-Language Pathology [PDF].

Interpreters may also be needed. Interpreting in telepractice may be done by videoconferencing or by telephone. Videoconferencing (or video interpreting) has the benefit of exchanging visual information. If using video interpreting, the interpreter may be located at the clinician site, the patient site, or a third separate site. Clinicians and facilitators should practice and become familiar with communicating with an interpreter in telepractice, including privacy and ethical concerns related to utilizing an interpreter. The hierarchy for preferred interpreters in telepractice is consistent with that used for interpreters during in-person practice (see ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators).

Privacy and Security

Practitioners should be aware of federal and state regulations relating to administrative, physical, and technical safeguards applicable to privacy and security, including those pertaining to storage, transmission, and disposal of client information.

Best practice is to use encrypted videoconferencing platforms to protect client confidentiality. The provider should be able to demonstrate encryption of the platform used for practice. Please see ASHA’s resource on Telepractice Services and Coronavirus/COVID-19 for further information.

Clinicians providing services via telepractice are bound by federal and state regulations as they would be when providing in-person services. The following federal legislation addresses privacy and security for covered entities:

• HIPAA (U.S. Department of Health and Human Services, n.d.-b)
• Health Information Technology for Economic and Clinical Health Act of 2009 (U.S. Department of Health and Human Services, n.d.-a)
• Family Educational Rights and Privacy Act of 1974 (U.S. Department of Education, n.d.)

States may also have privacy or security requirements that are more stringent than federal requirements. See ASHA’s resource on Health Insurance Portability and Accountability Act for general information about HIPAA. See also ASHA’s resource on HIPAA Security Technical Safeguards.

Determining how to be compliant with these regulations is complex. There are no absolute standards that dictate which software programs meet all requirements. Consulting an expert who specializes in these issues is advisable. Further discussion of the complexities of privacy is provided in the work of Cohn and Watzlaf (2011).

Security of treatment rooms and remote access to electronic documentation must be considered to protect client privacy and confidentiality at both sites. Clients should be given an opportunity to decide who is present at their location when they receive services, and a camera may be used to scan the clinician’s environment to ensure privacy. All persons in rooms at both sites should be identified prior to each session and when any individual(s) enters the room.

Clinicians obtain documentation of informed consent from the client (see Principle I, Rule H of the ASHA Code of Ethics (ASHA, 2023) to manage risk. This may include

• a description of the equipment and services to be delivered,
• how services via telepractice may differ from services delivered in person,
• the individual’s right to revert to traditional face-to-face care at any time,
• any modifications that will be made in assessment protocols, and
• potential confidentiality issues.

Documentation may also include

• the type(s) of equipment used,
• the identity of every person present,
• the location of the client and the clinician, and
• the type and rate of transmission.

Client confidentiality should be maintained regardless of the mode of service delivery (i.e., in-person or telepractice). Please see Principle I, Rules O and P of the ASHA Code of Ethics (ASHA, 2023). Telepractice confidentiality concerns include

• protection of confidential information so that it is available only when legally authorized or required by law;
• state and federal regulations pertaining to electronic storage of consumer information for local computer servers and local area networks, servers shared by wide area networks, and servers accessible by Internet users;
• types of technologies with privacy protections, including new or evolving forms of software and hardware solutions to ensure consumer privacy (e.g., encryption, VPN, firewalls);
• the need for telepractice software and hardware applications to be configured for use with encryption, VPN, or firewall applications;
• applications of VPN software, including downloading and configuring VPN software for modem and satellite connections;
• principles for training support and professional personnel concerning appropriate local standards for privacy of health care information of consumers; and
• a breach notification policy.

Enlisting Stakeholder Support

When implementing a telepractice program, it is essential for practitioners to gain the support of stakeholders. A successful telepractice program requires mutual understanding, collaboration, and a receptive attitude toward telepractice on the part of all stakeholders.

Methods for enlisting support include

• adding telepractice to the organization’s strategic plan to ensure administrative support and adequate allocation of resources;
• integrating telepractice program needs into existing organizational processes, personnel networks, and training activities;
• conducting pre-implementation planning with technical support staff to troubleshoot firewall and bandwidth issues;
• learning about and advocating for reimbursement mechanisms to sustain telepractice programs;
• educating staff on roles and responsibilities and the organization’s plan for provider training, quality assurance, provider and client/caregiver/student/parent satisfaction, and ongoing program development; and
• conducting outreach to the community, including satisfaction surveys.

Employment in Telepractice

Telepractice may be one aspect of an institution’s or a company’s services, or it may be the exclusive focus. Audiologists and SLPs may have questions regarding how to determine whether a prospective employer provides appropriate training and support to enable them to deliver high-quality services.

The following are questions that could be explored by a potential telepractitioner:

• Is the clinician an employee of the company or an independent contractor?
• Does the employer provide health insurance, retirement, and/or malpractice insurance?
• Does the employer assist with securing additional state licenses if the practice is to be multistate? Who pays for the license?
• What training is provided to the clinician, and does the clinician have to demonstrate competencies in the use and knowledge of telepractice that align with ASHA’s guidance?
• What kind of ongoing technical and clinical support does the employer provide to the clinician?
• Does the employer benchmark telepractice outcomes with on-site (traditional) outcomes to ensure equivalent levels of service?
• How does the employer support and facilitate communication with other stakeholders outside the therapy session (e.g., teachers, family members, rehab team, IEP meetings)?
• How do the employer’s policies and technology protect client privacy and security?
• What equipment, applications, online platforms, documentation systems, or other technology does the employer provide?
• What features does the employer’s provided technology offer (e.g., camera zoom, picture-in-picture)?
• Does the employer have business associate agreements with necessary companies, particularly if it shares protected health information with third-party payers?
• Who is responsible for serving as the facilitator (e.g., teacher’s aide, audiology assistant or speech-language pathology assistant, other support personnel, or interpreter)?
• To what extent has the facilitator been trained, and how will ongoing training be provided?

ASHA Resources

• ASHA State-by-State
• Audiology and Speech-Language Pathology Associations Outside of the United States
• Considerations for Group Speech-Language Pathology Treatment in Telepractice
• Considerations for Speech, Language, and Cognitive Assessment via Telepractice
• Facilitator Checklist for Telepractice Services in Audiology and Speech-Language Pathology [PDF]
• Health Care Telepractice Success Is All About the Prep
• Interstate Telepractice Regulations [PDF]
• Payment and Coverage of Telepractice Services: Considerations for Audiologists and Speech-Language Pathologists
• Serving Clients in Other States and Countries Through Telepractice in a Private Practice
• Serving Students in Other States and Countries Through Telepractice
• Teleassessment
• Telepractice Checklist for School-Based Professionals [PDF]
• Telepractice Considerations: Neurogenic Communication Disorders [Video]
• Telepractice Documentation Data Checklist for School-Based SLPs [PDF]
• Telepractice for SLPs in Health Care: Where do I Start? [Video]
• Telepractice for Speech and Hearing Services Brochure [PDF]
• Telepractice: Providing Audiology and Speech-Language Pathology Services at a Distance [Video]
• The Benefits of Telepractice in Audiology [PDF]
• The Value of Telepractice in Speech-Language Pathology [PDF]
• Tips for Conducting Speech Assessments Via Telepractice
• What to Expect at the End of the Public Health Emergency: Telepractice 
• 2014 SIG 18 Telepractice Services Survey Results [PDF]
• 2016 SIG 18 Telepractice Survey Results [PDF]

Ethics and Privacy

• Ethical Considerations for Client-Centered Telepractice
• Health Insurance Portability and Accountability Act
• HIPAA Security Technical Safeguards

Considerations for COVID-19

• COVID-19: ASHA Web Event Series on Service Delivery Considerations for Private Practice in Speech-Language Pathology
• COVID-19: ASHA Web Event Series on Service Delivery Considerations in Early Intervention
• Dysphagia and Telepractice During COVID-19 and Beyond [Video]
• Swallowing and Feeding Services in Schools via Telepractice During COVID-19

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Telemedicine Association
• A Blueprint for Telerehabilitation Guidelines
• Center for Connected Health Policy
• Center for Telehealth and e-Health Law
• National Center for Hearing Assessment and Management: A Practical Guide to the Use of Tele-Intervention in Providing Early Intervention Services to Infants and Toddlers Who Are Deaf or Hard of Hearing
• National Center for Hearing Assessment and Management: Timely Diagnosis and Follow-Up: A Resource Guide Supporting Tele-Audiology
• National Consortium of Telehealth Resource Centers
• National Telehealth Technology Assessment Resource Center
• RCSLT: New Long COVID Guidance and Patient Handbook
• Rural Health Information Hub
• Supporting Aided Augmentative and Alternative Communication Interventions for Individuals With Complex Communication Needs via Telepractice: A Tutorial
• U.S. Department of Health & Human Services – Centers for Medicare & Medicaid Services: Telehealth Services Medicare Learning Network Article [PDF]
• U.S. Department of Health & Human Services – Health Resources & Services Administration: Telehealth Programs
• U.S. Department of Veterans Affairs: VA Telehealth Services

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Biagio, L., Swanepoel, D. W., Adeyemo, A., Hall, J. W., III, & Vinck, B. (2013). Asynchronous video-otoscopy with a telehealth facilitator. Telemedicine and e-Health, 19(4), 252–258. https://doi.org/10.1089/tmj.2012.0161

Biagio, L., Swanepoel, D. W., Laurent, C., & Lundberg, T. (2014). Video-otoscopy recordings for diagnosis of childhood ear disease using telehealth at primary health care level. Journal of Telemedicine and Telecare, 20(6), 300–306. https://doi.org/10.1177/1357633X14541038

Boisvert, M. K., & Hall, N. (2019). Telepractice for school-based speech and language services: A workload management strategy. Perspectives of the ASHA Special Interest Groups, 4(1), 211–216. https://doi.org/10.1044/2018_PERS-SIG18-2018-0004

Botasso, M., Sanches, S. G. G., Bento, R. F., & Samelli, A. G. (2015). Teleaudiometry as a screening method in school children. Clinics, 70(4), 283–288. https://doi.org/10.6061/clinics/2015(04)11

Brennan, D. M., Georgeadis, A. C., Baron, C. R., & Barker, L. M. (2004). The effect of videoconference-based telerehabilitation on story retelling performance by brain-injured subjects and its implications for remote speech-language therapy. Telemedicine Journal and e-Health, 10(2), 147–154. https://doi.org/10.1089/tmj.2004.10.147

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Campos, P. D., & Ferrari, D. V. (2012). Teleaudiology: Evaluation of teleconsultation efficacy for hearing aid fitting. Jornal da Sociedade Brasileira de Fonoaudiologia, 24(4), 301–308. https://doi.org/10.1590/S2179-64912012000400003

Carey, B., O’Brian, S., Lowe, R., & Onslow, M. (2014). Webcam delivery of the Camperdown Program for adolescents who stutter: A phase II trial. Language, Speech, and Hearing Services in Schools, 45(4), 314–324. https://doi.org/10.1044/2014_LSHSS-13-0067

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Carlew, A. R., Fatima, H., Livingstone, J. R., Reese, C., Lacritz, L., Pendergrass, C., Bailey, K. C., Presley, C., Mokhtari, B., & Cullum, C. M. (2020). Cognitive assessment via telephone: A scoping review of instruments. Archives of Clinical Neuropsychology, 35(8), 1215–1233. https://doi.org/10.1093/arclin/acaa096

Cassel, S. G. (2016). Case reports: Trial dysphagia interventions conducted via telehealth. International Journal of Telerehabilitation, 8(2), 71–76. https://doi.org/10.5195/ijt.2016.6193

Choi, J. M., Lee, H. B., Park, C. S., Oh, S. H., & Park, K. S. (2007). PC-based tele-audiometry. Telemedicine and e-Health, 13(5), 501–508. https://doi.org/10.1089/tmj.2007.0085

Coco, L., Davidson, A., & Marrone, N. (2020). The role of patient-site facilitators in teleaudiology: A scoping review. American Journal of Audiology, 29(3S), 661–675. https://doi.org/10.1044/2020_AJA-19-00070

Cohn, E. R., & Cason, J. (2019). Ethical considerations for client-centered telepractice. Perspectives of the ASHA Special Interest Groups, 4(4), 704–711. https://doi.org/10.1044/2019_PERS-SIG18-2019-0001

Cohn, E. R., & Watzlaf, V. J. M. (2011). Privacy and Internet-based telepractice. SIG 18 Perspectives on Telepractice, 1(1), 26–37. https://doi.org/10.1044/tele1.1.26

Coleman, J. J., Frymark, T., Franceschini, N. M., & Theodoros, D. G. (2015). Assessment and treatment of cognition and communication skills in adults with acquired brain injury via telepractice: A systematic review. American Journal of Speech-Language Pathology, 24(2), 295–315. https://doi.org/10.1044/2015_AJSLP-14-0028

Coufal, K., Parham, D., Jakubowitz, M., Howell, C., & Reyes, J. (2018). Comparing traditional service delivery and telepractice for speech sound production using a functional outcome measure. American Journal of Speech-Language Pathology, 27(1), 82–90. https://doi.org/10.1044/2017_AJSLP-16-0070

Crutchley, S., & Campbell, M. (2010). TeleSpeech Therapy pilot project: Stakeholder satisfaction. International Journal of Telerehabilitation, 2(1), 23–30. https://doi.org/10.5195/ijt.2010.6049

Crutchley, S., Dudley, W., & Campbell, M. (2010). Articulation assessment through videoconferencing: A pilot study. Communications of Global Information Technology, 2, 12–23.

Denton, D. R., & Gladstone, V. S. (2005). Ethical and legal issues related to telepractice. Seminars in Hearing, 26(1), 43–52. https://doi.org/10.1055/s-2005-863794

Doarn, C. R., Zacharias, S., Keck, C. S., Tabangin, M., DeAlarcon, A., & Kelchner, L. (2019). Design and implementation of an interactive website for pediatric voice therapy—the concept of in-between care: A telehealth model. Telemedicine and e-Health, 25(5), 415–422. https://doi.org/10.1089/tmj.2018.0108

Donne, V. (2013). Technology to support sign language for students with disabilities. Rural Special Education Quarterly, 32(4), 24–37. https://doi.org/10.1177/875687051303200404

Douglass, H., Lowman, J. J., & Angadi, V. (2021). Defining roles and responsibilities for school-based tele-facilitators: Intraclass correlation coefficient (ICC) ratings of proposed competencies. International Journal of Telerehabilitation, 13(1), e6351. https://doi.org/10.5195/ijt.2021.6351

Duane, J. N., Blanch-Hartigan, D., Sanders, J. J., Caponigro, E., Robicheaux, E., Bernard, B., Podolski, M., & Ericson, J. (2021, April 24). Environmental considerations for effective telehealth encounters: A narrative review and implications for best practice. Telemedicine and e-Health. Advance online publication. https://doi.org/10.1089/tmj.2021.0074

Eikelboom, R. H., Atlas, M. D., Mbao, M. N., & Gallop, M. (2002). Tele-otology: Planning, design, development and implementation. Journal of Telemedicine and Telecare, 8(3), 14–17. https://doi.org/10.1258/13576330260440718

Eikelboom, R. H., Jayakody, D. M. P., Swanepoel, D. W., Chang, S., & Atlas, M. D. (2014). Validation of remote mapping of cochlear implants. Journal of Telemedicine and Telecare, 20(4), 171–177. https://doi.org/10.1177/1357633X14529234

Ferrari, D. V., & Bernardez-Braga, G. R. A. (2009). Remote probe microphone measurement to verify hearing aid performance. Journal of Telemedicine and Telecare, 15(3), 122–124. https://doi.org/10.1258/jtt.2009.003005

Gabel, R., Grogan-Johnson, S., Alvares, R., Bechstein, L., & Taylor, J. (2013). A field study of telepractice for school intervention using the ASHA NOMS K-12 database. Communication Disorders Quarterly, 35(1), 44–53. https://doi.org/10.1177/1525740113503035

Grogan-Johnson, S. (2021). The five W’s meet the three R’s: The who, what, when, where, and why of telepractice service delivery for school-based speech-language therapy services. Seminars in Speech and Language, 42(02), 162–176. https://doi.org/10.1055/s-0041-1723842

Grogan-Johnson, S., Alvares, R., Rowan, L., & Creaghead, N. (2010). A pilot study comparing the effectiveness of speech language therapy provided by telemedicine with conventional on-site therapy. Journal of Telemedicine and Telecare, 16(3), 134–139. https://doi.org/10.1258/jtt.2009.090608

Grogan-Johnson, S., Gabel, R. M., Taylor, J., Rowan, L. E., Alvares, R., & Schenker, J. (2011). A pilot exploration of speech sound disorder intervention delivered by telehealth to school-age children. International Journal of Telerehabilitation, 3(1), 31–42. https://doi.org/10.5195/ijt.2011.6064

Grogan-Johnson, S., Schmidt, A. M., Schenker, J., Alvares, R., Rowan, L. E., & Taylor, J. (2013). A comparison of speech sound intervention delivered by telepractice and side-by-side service delivery models. Communication Disorders Quarterly, 34(4), 210–220. https://doi.org/10.1177/1525740113484965

Hall, N., Boisvert, M., & Steele, R. (2013). Telepractice in the assessment and treatment of individuals with aphasia: A systematic review. International Journal of Telerehabilitation, 5(1), 27–38. https://doi.org/10.5195/ijt.2013.6119

Halpern, A. E., Ramig, L. O., Matos, C. E. C., Petska-Cable, J. A., Spielman, J. L., Pogoda, J. M., Gilley, P. M., Sapir, S., Bennet, J. K., & McFarland, D. H. (2012). Innovative technology for the assisted delivery of intensive voice treatment (LSVT LOUD) for Parkinson disease. American Journal of Speech-Language Pathology, 21(4), 354–367. https://doi.org/10.1044/1058-0360(2012/11-0125)

Higgins, W. J., Luczynski, K. C., Carroll, R. A., Fisher, W. W., & Mudford, O. C. (2017). Evaluation of a telehealth training package to remotely train staff to conduct a preference assessment. Journal of Applied Behavior Analysis, 50(2), 238–251. https://doi.org/10.1002/jaba.370

Hill, A. J., Theodoros, D. G., Russell, T. G., Cahill, L. M., Ward, E. C., & Clark, K. M. (2006). An Internet-based telerehabilitation system for the assessment of motor speech disorders: A pilot study. American Journal of Speech-Language Pathology, 15(1), 45–56. https://doi.org/10.1044/1058-0360(2006/006)

Hughes, M. L., Goehring, J. L., Baudhuin, J. L., Diaz, G. R., Sanford, T., Harpster, R., & Valente, D. L. (2012). Use of telehealth for research and clinical measures in cochlear implant recipients: A validation study. Journal of Speech, Language, and Hearing Research, 55(4), 1112–1127. https://doi.org/10.1044/1092-4388(2011/11-0237)

Iacono, T., Dissanayake, C., Trembath, D., Hudry, K., Erickson, S., & Spong, J. (2016). Family and practitioner perspectives on telehealth for services to young children with autism. Studies in Health Technology and Informatics, 231, 63–73.

Jarvis-Selinger, S., Chan, E., Payne, R., Plohman, K., & Ho, K. (2008). Clinical telehealth across the disciplines: Lessons learned. Telemedicine and e-Health, 14(7), 720–725. https://doi.org/10.1089/tmj.2007.0108

Khoza-Shangase, K., & Moroe, N. (2020). South African hearing conservation programmes in the context of tele-audiology: A scoping review. South African Journal of Communication Disorders, 67(2), e1–e10.

Kokesh, J., Ferguson, A. S., Patricoski, C., Koller, K., Zwack, G., Provost, E., & Holck, P. (2008). Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska. Otolaryngology—Head and Neck Surgery, 139(1), 87–93. https://doi.org/10.1016/j.otohns.2008.04.008

Kokesh, J., Ferguson, A. S., Patricoski, C., & LeMaster, B. (2009). Traveling an audiologist to provide otolaryngology care using store-and-forward telemedicine. Telemedicine and e-Health, 15(8), 758–763. https://doi.org/10.1089/tmj.2009.0046

Krumm, M., Huffman, T., Dick, K., & Klich, R. (2007). Providing infant hearing screening using OAEs and AABR using telehealth technology. Journal of Telemedicine and Telecare, 14(2), 102–104.

Krumm, M., Ribera, J., & Klich, R. (2007). Providing basic hearing tests using remote computing technology. Journal of Telemedicine and Telecare, 13(8), 406–410. https://doi.org/10.1258/135763307783064395

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Kurland, J., Liu, A., & Stokes, P. (2018). Effects of a tablet-based home practice program with telepractice on treatment outcomes in chronic aphasia. Journal of Speech, Language, and Hearing Research, 61(5), 1140–1156. https://doi.org/10.1044/2018_JSLHR-L-17-0277

Kuzovkov, V., Yanov, Y., Levin, S., Bovo, R., Rosignoli, M., Eskilsson, G., & Willbas, S. (2014). Remote programming of MED-EL cochlear implants: Users’ and professionals’ evaluation of the remote programming experience. Acta Oto-Laryngologica, 134(7), 709–716. https://doi.org/10.3109/00016489.2014.892212

Lancaster, P., Krumm, M., Ribera, J., & Klich, R. (2008). Remote hearing screenings via telehealth in a rural elementary school. American Journal of Audiology, 17(2), 114–122. https://doi.org/10.1044/1059-0889(2008/07-0008)

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Telepractice page:

• Robin L. Alvares, PhD, CCC-SLP
• Michael F. Campbell, MS, MBA, CCC-SLP
• Laura Coco, PhD, AuD, CCC-A
• Ellen R. Cohn, PhD, CCC-SLP
• Lyn R. Covert, PhD, CCC-SLP
• Gregg D. Givens, PhD, CCC-SLP
• Chad F. Gladden, AuD, CCC-A
• Susan Grogan-Johnson, PhD, CCC-SLP
• Philip J. Hofstetter, AuD, CCC-A
• Melissa D. Jakubowitz, MA, CCC-SLP
• Elaine R. Kalous, AuD, CCC-A
• Joneen Lowman, PhD, CCC-SLP
• Michael P. Towey, MA, CCC-SLP

In addition, ASHA thanks the members of the Ad Hoc Committee on Telepractice in Speech-Language Pathology and the Telepractice Working Group whose work was foundational to the development of this content.

Members of the Ad Hoc Committee on Telepractice in Speech-Language Pathology were Pauline Mashima (chair), David M. Brennan, Michael Campbell, Diana Christiana, Vickie Pullins, and Janet Brown (ex officio). Vice Presidents for Professional Practices in Speech-Language Pathology Brian Shulman (2006–2008) and Julie Noel (2009–2011) served as the monitoring officers. ASHA staff members Janice Brannon and Amy Hasselkus also contributed.

Members of the ASHA Telepractice Working Group were Mark Krumm (chair), Gregg Givens, Amy C. Georgeadis, Pauline A. Mashima, John M. Torrens, Janet Brown (ex officio), and Pamela Mason (audiology staff consultant). Roberta B. Aungst, vice president for professional practices in audiology (2004–2006), served as monitoring vice president.

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for the Practice Portal page is:

American Speech-Language-Hearing Association (n.d.). Telepractice. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Telepractice/.