The Implementation of Telepractice in Speech Language Pathology in Hong Kong During the COVID-19 Pandemic

Introduction

Telepractice is the application of telecommunication technologies in health and medical services.¹ It facilitates cost-effective, quality, and flexible health and social services even when the service provider and the recipients are at a distance to each other.² Telepractice can bring services to rural areas, as well as enabling professionals to see a high volume of clients and increase the impact of services in these communities.³ It is a recognized service delivery model in the field of speech language pathology,⁴ as evidenced by the inclusion of it in the American Speech Language Hearing Association (ASHA) Scope of practice. Speech Pathology Australia also published a position statement in 2014 on this matter.⁵ Telepractice in speech language pathology is not confined to service provision in rural areas.⁶ It was also advocated to overcome barriers of access to services such as unavailability of specialists and impaired mobility of patients.

Telepractice is an effective service delivery model across a spectrum of disorders, including childhood speech and language disorders,^7,8 fluency disorders,^9,10 neurogenic communication disorders,^11–13 and dysphagia.^14,15 Most areas of speech language pathology practice have evidence supporting the use of telepractice as a model of service delivery, with adaptation using technologies, for example, the use of both synchronous and store-and-forward components.^16,17 Telepractice in speech language pathology has not only yielded positive clinical outcome, patients’ responses have also been favorable, particularly in patients with an interest in technology.⁶

The perception and application by speech language pathologists (SLPs) have been investigated by using surveys in different parts of the world. ASHA has been conducting surveys with its members on this topic since 2002, and most recently in an organization-wide survey with 569 respondents who were either SLPs or audiologists.¹⁸ For the 476 SLPs, 64.1% were currently providing telepractice and over half (57.0%; 175/307) of those had already been doing so for >3 years. Nearly all (96.4%; 292/303) were using telepractice to provide treatment, whereas 60.7% (184/303) provided assessment. The most common clinical area was language disorders (73.5%; 219/298) followed by articulation/phonological disorders (70.5%; 210/298). The survey also included information about how members received training, their preparation for commencing telepractice, and their current state.

A survey done in Australia included only those who were already using telepractice in their service delivery and there were 57 valid responses.¹⁹ The majority of the respondents had been using telepractice for <6 years (80.8%). Similar to the ASHA survey, the majority of them (86.0%) used telepractice for treatment and 40.4% of them used it for assessment. The clinical population that was most common was expressive language and fluency for pediatrics, fluency and dysarthria for adults. The survey also included the respondents’ perception of the benefits, barriers, and facilitators in using telepractice and the responses were generally positive.

A survey was also done in India with 205 SLPs and audiologists as respondents,¹⁷ the number of respondents who used telepractice was much lower at 12.2%. In their respondents, the most common service delivered was follow-up/monitoring, in 27.8% of respondents, followed by management in 20.8% and assessment in 19.4%. The most common clinical population was also speech sound disorders in children, by 12.1% of respondents, followed by patients with learning disabilities in 9.7% of respondents. The survey also included results of the respondents’ views on training, research, as well as policies and guidelines.

There were two more surveys conducted on the use of telepractice in speech language pathology that investigated more specific areas. One study by Grillo et al.²⁰ investigated the costing, methodology differences between face-to-face, and telepractice. The types of learning opportunities offered through telepractice and the manipulation of the clients’ environment were also investigated. The information from the study supplemented the existing work of previous surveys and facilitated the development of service delivery model in telepractice. Another study by Tucker²¹ surveyed school-based SLPs on the use of telepractice. The study concluded that there was a need to establish procedures and guidelines for school-based telepractice programs to ensure its validity.²¹

Geographical limitation is certainly an incentive and valid reason for implementing telepractice. This limitation alone may not hold, however, for cities such as Hong Kong, with an area of 1,106 square kilometers and a population of 7.5 million.²² It is one of the most densely populated areas in the world and the accessibility of medical services, including speech language pathology, is often not limited by physical distance. This would be the most reasonable postulation that telepractice in speech language pathology, or other areas of rehabilitation, was not as common in Hong Kong than in other parts of the world. This was true until the pandemic of the coronavirus disease 2019 (COVID-19) affected the region in January 2020.²³ The city commenced its lockdown state with schools and early education centers in complete shutdown. Hospitals, nursing homes, and clinics had nonessential services suspended and employed strict visitor policy, in conjunction with the social distancing measures since late January 2020.²³ Speech language pathology services were affected in all clinical populations, and SLPs in different settings started to explore telepractice for service delivery, similar to other medical professions.²⁴

In light of this, a survey on SLPs was conducted. The research questions for this survey are (1) what is the current practice of telepractice in speech language pathology in Hong Kong, (2) how is telepractice perceived by SLPs in Hong Kong and what do they know about it, and (3) what training has been conducted and what are the possibilities in the development of this field? It was hoped that with the information, the emergence of telepractice in a metropolis because of a pandemic such as COVID-19 can be better understood. Whether, and how does, the perception and knowledge of SLPs interact with the implementation of telepractice in such a short time frame would also be understood. It was also anticipated that training and further development of this area could be better recognized after an accelerated implementation of telepractice due to the pandemic.

Materials and Methods

A survey was developed to gather responses from SLPs in Hong Kong. Questions in the survey were formulated based on a literature review of similar surveys conducted and the guidelines/position statements issued by various professional bodies across the world. The survey had four sections. The first section was demographics that asked respondents about their experience, work setting, and current caseload. The second section was split into two, one on the existing telepractice delivery for those who were providing telepractice and perception toward telepractice to those who were not. The subsequent sections covered respondents’ views on training and knowledge of telepractice. There were 12 to 15 questions depending on whether the respondents were engaged in telepractice or not and required <10 min for participants to complete. The full survey is included in Appendix A1.

The survey was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (Reference No. SBRE-19-522). The survey was distributed through e-mail and instant messaging to SLPs in Hong Kong. Convenience sampling was used to recruit participants; consent was implied by completing the survey. No identifiable personal information was collected to ensure anonymity. Data were collected for a 10-day period, February 23–March 3, 2020. Descriptive statistics were used for analysis. Responses to open questions were analyzed qualitatively using thematic analysis.

Results

A total of 135 SLPs responded to the survey, with mean years of experience of 8.11 ± 7.12 years. At the time of the survey, 35% (47/135) had provided clinical services through telepractice, whereas 65% (88/135) had not. The work setting and the case types are presented in Table 1.

Existing Service Delivery in Telepractice

The 47 respondents who have done telepractice responded to seven questions regarding their service delivery in this section. On the duration of telepractice, 72.3% (34/47) have been doing telepractice only for <3 months, 8.5% (4/47) for 3–12 months, 6.4% (3/47) for 1–3 years, and 6 of them (12.8%) for >3 years. As for the frequency, 21.3% (10/47) reported that telepractice was a one-off occasion, 23.4% (11/47) did it for less than once per week, 48.9% (23/47) did it 1–5 times per week, and 6.4% (3/47) did it >5 times per week. For the patients’ age group, the results are presented in Table 2. The most common age group that respondents did telepractice on was the school-age group (6–17 years old) followed by preschool group (3–5 years old). No respondent did telepractice on patients younger than 6 months old. For service delivery, >70% did treatment (70.2%; 33/47), followed by follow-up/monitoring at 59.6% (28/47), and consultation, such as supervision services, at 34.0% (16/47). In the 47 respondents, 17.0% (8/47) and 14.9% (7/47) did screening and assessment, respectively. The clinical population that telepractice has been done is detailed in Table 2, with the most common one being developmental language disorder and followed by speech sound disorders. For mode of delivery, 70.2% (33/47) did it over videoconferencing, 51.1% (24/47) did so through telephone, whereas 23.4% (11/47) did it through a store-and-forward approach. The last question involved their perception of the effectiveness of telepractice, for which 51.1% (24/47) felt it was less effective compared with face-to-face service, 25.5% (12/47) felt it was similarly effective. Six of the respondents (12.8%) have not considered the effectiveness and no respondents felt it was more effective than face-to-face service.

Perception of Telepractice

For the 88 respondents who had not conducted telepractice, four questions were asked about their perception of telepractice. The majority of them (81.8%; 72/88) were aware of telepractice in speech language pathology, whereas 18.2% (16/88) were not aware. However, only 56.8% (50/88) felt that telepractice could be applied in speech language pathology, 20.5% (18/88) felt that it could not, and the others were either “uncertain” or “not sure.” We asked the participants what additional hardware/clinical materials were needed to set up an effective telepractice in an open-ended question format. Respondents’ replies were analyzed and grouped into four main categories including hardware, software, training, and environment modification, examples of their responses are presented in Table 3. The last question was on the reason(s) of not using telepractice yet and most responded that patient and age type were not suitable as being the main factor (83.0%; 73/88). Other factors included lack of support/resources/training (55.7%; 49/88), impersonal/lack of physical contact (52.2%; 46/88), and technological barrier (50.0%; 44/88). The factors fewer respondents answered were questionable effectiveness (40.9%; 36/88), clients’ or caregivers’ refusal (33.0%; 29/88), no need for change (25.0%; 22/88), ethical concern (13.6%; 12/88), and cost too high (5.7%; 5/88).

Training and Knowledge About Telepractice

All respondents were asked two questions about training, one on their past training on telepractice and another one on the additional training desired on this topic. Of 135 respondents, 60.0% (81/135) never had any training on telepractice. For those who had prior training, 23.7% (32/135) had interprofessional exchange, 7.4% (10/135) attended professional development events, or self-studied with literature, books, or guidelines. Only 6.7% (9/135) received training on this aspect in their studies and 2.2% (3/135) received technical training. For training that respondents anticipated, 89.6% (121/135) indicated they desired training in this area. About half (43.7%; 59/135) of the respondents wanted training on the clinical aspects, followed by the technology involved (37.8%; 51/135), training on specific programs tailored for telepractice (25.1%; 34/135), and 6.7% (9/135) of them welcomed interprofessional exchanges. For this question, 11.9% (16/135) of respondents either did not indicate they desire training or had no idea what training would be needed. All participants were also given four statements or concepts that were taken from the Position Statement on Telepractice published by Speech Pathology Australia⁵ and the ASHA practice portal on telepractice.¹ Respondents had to rate their level of agreement to the statement that could reflect their understanding of concepts in telepractice. The statement that achieved the most consensus was “The appropriateness of telepractice depends on the clinical population,” for which 89.6% (121/135) either agreed or strongly agreed to this statement. The rest of the results are detailed in Table 4. The last question of the survey asked about patient candidacy for telepractice. Nearly all respondents (99.3%; 134/135) indicated patients’ cognitive and behavioral ability, followed by patients’ access to support services (92.6%; 125/135), physical and sensory ability (91.1%; 123/135), communication ability (87.4%; 118/135), and clinical condition (78.5%; 106/135).

Discussion

This survey was the first of its kind done in the region that investigated the use of telepractice in speech language pathology. More importantly, it was done in a city region during the pandemic of COVID-19, which could indicate how telepractice showed an accelerated emergence due to the pandemic, in an area otherwise that did not favor the development of telepractice because of the high accessibility of services geographically. The results of this survey are important not only to the development of telepractice in Hong Kong but also as an indicator of the emergence and development of telepractice in other densely populated cities of the world.

Comparison of Telepractice: Hong Kong and other Parts of the World

Only 13% (6/47) of the telepractitioners in Hong Kong had started the service for >3 years. When compared with the organization-wide survey of ASHA in 2016, over half (57.0%; 175/307) had started telepractice for >3 years.¹⁸ The COVID-19 pandemic likely accelerated the use of telepractice in Hong Kong, as an alternative for service delivery during the lockdown. School-age children (6–17 years old) were the most common age group that received telepractitioners’ service, followed by preschool children (3–5 years old). The data closely aligned with those reported by ASHA 2016. This may indicate that school-age and preschool clients are more suitable for receiving rehabilitation through technologies, and with the least resistance to commence service as compared with other age groups such as those >65 years old or <6 months. The study from Tucker²¹ also supported that telepractice in the educational setting could be a beneficial model of service delivery for students with communication problems.

Regarding the clinical population receiving telepractice, the top two clinical populations (developmental language disorders and speech sound disorders) were consistent with that of the United States¹⁸ and Australia.⁵ However, the use of telepractice in dysphagia and feeding problems locally was unexpectedly higher than that in the United States and Australia. In the United States and Australia, only 7% of their respondents were providing dysphagia services through telepractice,^18,19 compared with 34% in Hong Kong. As dysphagia can lead to aspiration pneumonia that contributes to morbidity and mortality in the elderly,²⁵ it should be cautioned that the benefits and risks of telepractice in dysphagia are defined and balanced. Ward et al.¹⁴ suggested that prior training and preparation were essential for assessing more complex dysphagic clients in telerehabilitation. From this survey, we did not further ask how telepractice services were set up in different clinical populations, so it was not clear whether prior training and preparation were done fully in this clinical area.

Our survey found that telepractitioners in Hong Kong mainly provided treatment through telepractice, whereas screening or assessment was done much less. In contrast, ASHA’s data showed that treatment and assessment were the top two services through telepractice. It could be speculated that our respondents chose to start telepractice with patients they were already familiar with instead of new patients, as most of our respondents had just begun telepractice not long ago. We believe this is sensible and would be typical in how face-to-face services transition to telepractice. However, emerging evidence also supported that telepractice is a viable and reliable means for screening or assessment in specific areas, including articulation screening,²⁶ aphasia assessment,²⁷ and poststroke dysphagia evaluation.¹⁵ The use of telepractice in assessment and screening is likely to be more common as SLPs gather experience on this model of service delivery.

Mode of Service Delivery

Telehealth service delivery models can be categorized into real-time interaction technology (synchronous) and store-and-forward technology (asynchronous). The use of a hybrid model combining synchronous and asynchronous technology was reported in most of the recent publications on telepractice application in speech language pathology.²⁸ However, in our study, only 23.4% have used asynchronous methods, whereas 7.4% (10/135) have used both methods. Although real-time interaction is essential for telepractice, store-and-forward technology can also be considered as a primary or adjunctive means for providing telepractice.⁶ The practice of using a synchronous method would likely be how emerging telepractice is, but clinicians should also consider the use of asynchronous or hybrid approach to suit the needs of individual patients.

Setting of Telepractitioners

Subgroup analysis was done on the proportion of telepractitioners to nontelepractitioners in different work settings. The proportion of telepractitioners was greatest for those working in hospitals, whereas the least was nursing homes. The high utilization of telepractice in hospitals could be triggered by the lockdown state in hospitals due to the pandemic of the COVID-19 since early 2020, with most nonurgent outpatient services suspended. SLPs in the hospitals commenced telepractice as an interim measure to sustain nonessential, or even essential, services. Regarding the limited availability of telepractice in nursing homes, this may be attributed to the common barriers in nursing homes, including hardware/technology and telecommunication connections, as reported in another survey.¹⁹

Knowledge and Training

One astounding finding from our survey was the knowledge and perception of the clinical efficacy of telepractice. Only 27% of respondents agreed whereas most were neutral to the statement that “telepractice is based on evidence-based practice and is at least equivalent to standard clinical care.” This was taken from the position statement from Speech Pathology Australia and numerous studies have been done to show that telepractice is comparable with, and sometimes more effective than, face-to-face services. The level of agreement for telepractitioners for this statement was not much higher, only at 57%. Furthermore, in our respondents who had been using telepractice, half of them thought it is less effective than face-to-face service. These two results show that some SLPs locally have the misconception that telepractice is not as effective as standard face-to-face service. Those who had done telepractice were still skeptical about how effective telepractice could be. One of the ways to overcome this misconception is through professional development activities. The respondents of our survey mostly showed a welcoming attitude toward education in this area, with the most desired area of training on the clinical aspects, such as how telepractice can be implemented effectively in a particular clinical population, how to make the suitable adaptation in giving cues and feedback, etc. Telepractice has not been a topic of interest in continuing education for SLPs locally, the accelerated emergence of it due to the pandemic has already urged SLPs locally to keep up with the literature on this, and professional development events have been held.

Limitations and Future Direction

This survey only included SLPs who could be reached through e-mail or social media; although the sample was considered to be representative of the distribution of SLPs in different settings locally, some settings were not included such as hostels for people with intellectual disabilities, child assessment services operated by the government. Also, this was a cross-sectional survey that was done in late February this year, which coincided with the peak of COVID-19 pandemic locally. The survey would have more representative results of how the different stages of the pandemic affect the use of telepractice in speech language pathology if it was a longitudinal study, or at least at different time points along with the pandemic. It is anticipated that by the time of publication, the coverage of telepractice in the region would already be different. Nevertheless, the survey was able to show how an accelerated emergence of telepractice during the pandemic would happen in the field of speech language pathology.

Conclusions

The COVID-19 pandemic has brought dramatic changes to many aspects of our lives. Service delivery in speech language pathology was impacted significantly as well. The results of this survey were able to depict how telepractice emerged during this pandemic in a geographical region that does not favor its development. The results also showed the current situation of telepractice and the way ahead in terms of training and development needed. It is hoped that through this study, clinicians in regions in the world who telepractice are yet to emerge as a service delivery model will be able to make use of the findings as a foundation to establish their telepractice service.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.