This is not a graded or a writing assignment.

What do the researchers think this study contributes to

What are its limitations?

Transcribed Image Text:data storage; other optional modules include appointment sched- uling, billing, and reimbursement. The associated database stores patient information: patient demographics, medical records, family history, insurance information, and so on. Some of this information requires manual input (e.g., patient demographics); some is auto- matically recorded by the system (e.g., hearing thresholds). The patient site is where patient audiometric data are collected and forwarded to the server through the Internet. The patient site, equipped with an audiometer and an Internet access point, can be constructed in a community care center, nursing home, school, or patient home. The clinical professional site requires only an Internet access device with Web browser software installed. For both the patient and clinical professional sites, the Internet connection can be wired or wireless. With this system configuration, a hearing test can be conducted as long as both sides have access to the system server. The system works literally the same way regardless of the geographical locations of the patient and the clinical professions. They can be as close as in the same building, or may be located on two different continents. The system software is designed with browser-server architec- ture. Users (in this case, audiologists) access the Web services on the server through a standard Internet browser. The server monitors the presence of remote audiometers and provides a list of connected audiometer devices for audiologist selection. The audiologist selects the proper device from the list that is used by their patient. To allow coordination between the clinic professional site and the patient site when preparing for hearing test sessions, communica- tion means such as telephone or videoconference is needed. Once the testing starts, the audiologist operates the remote audiometer through "brows- ing" the hearing test Web page and observes patient responses as indicated by the Web page. To allow possible future system expansion, the application server is hosted on an IBM blade server running a virtual datacenter operating system ESX with 3.5 updates from VMware Inc. (Palo Alto, CA). Currently, a virtual machine with dual 3.4-GHz central processing units and 2-GB randomly accessible memory is used as the server. This configuration is equivalent to that of a typi- cal PC. The virtual machine is set up as a Windows 2003 Pro Virtual Server (Microsoft, Redmond, WA). Application software on the server is devel- oped under the Microsoft .NET framework. Home + Patent Information + Hearing Test + Hearing Test Results Device Status Left Right Connector AA |Stimulus|T||7 Mode PP WEB SERVICES-BASED TELE-AUDIOLOGY SYSTEM To avoid the issue of fat clients as opposed to thin clients as in cli- ent/server software architecture, the system employed browser/client architecture, where all the services were implemented on the server. No application tasks are completed by the user terminal computer. The user browser opens Web pages located on the server and all the operations are achieved by the server. This was achieved by adopt- ing Active Server Pages (ASP), a Web service programming method, when developing the Web pages. ASP is a program that runs within the Internet Information Services, a free component of the Windows operating system. ASP eliminates the need for executing any applica- tions on a user's terminal. Functions associated with the Web services were implemented by calling functions programmed in C#. Figure 2 shows the hearing test page on the application server as an example. For demonstration purposes, the database is also implemented on the same physical machine as the application server. In real systems, the database and the part of the program for application logics can be physically separated for the purposes of maintenance convenience. and affordability (separating database from application logics poten- tially reduces the requirements on the server's computation power and storage capacity). For the prototype, information stored in the database can be largely divided into three categories: user manage- ment, patient information, and test results. The database can (and. is expected to) be expanded to include appointment scheduling, accounting, insurance, reimbursement, and so on. Home > Heanne Test Current Patient Execute Result Get Device List Device Sunchronization Luft Right 125 0 X Frequency (Hz) Actual Frequency Level (db) Actual Level Connector Stimulus Mede Patient ID 50 TestTime 3/2/2009 4:12:26 PM OK East Carolina University Tele-Hearing Test Center www.Logout OPOD-0707-0008 Stimulation Duration (1) 2 250 0 X X X 750 X X 1000 -5 30 Stimule Left Left OP Text Results 1500 Air Conduction OBone Conduction Tone ONBN O Steady Pulsed Fig. 2. The hearing test page of the server site. X Name A Volunteer Device: OPOD-0707-0039 Remote Chestlp: 150.216.56.7 2000 0 X Copyright © Eart Carolina University 2008 3000 x X Air Conduction Ⓒ Tone O Steady 4000 -5 X Stimate Right Right -1000 30 -5 X D OBone Conduction ONBN Pulsed 8000 0 X YAO ET AL. The patient site was implemented with two pos- sible configurations, depending on the availability of access point devices to the Internet. If a PC or laptop is available, the audiometer can be con- nected to the computer through an EZURIO (Laird Technologies, St. Louis, MO) Bluetooth-USB adapt- er¹³ and exchanges data with the application server over the Internet. In cases where a computer is not available at the test site, a wireless Bluetooth-IP gateway device (Parani 1000, SENA Technologies, San Jose, CA) can be used to bridge the audiom- eter and the Internet. The clinical effectiveness of the prototype sys- tem was primarily evaluated from two perspec- tives: (1) the agreement of the hearing threshold findings obtained from the teletests to those from the conventional tests; and (2) the amount of time ECU Allied Health Building Patient that is required to conduct hearing tests using the two testing modes. In the current testing setup (Fig. 3), the subjects (audiometer via access device) and the audiologists (using an Internet browsing device) both access the Internet from a building on the medical campus at East Carolina University and exchange data through the application server located on the main campus. At the physical layer, the two campuses are connected with 1 gigabit per second fiber connections. Two Cisco (Cisco Systems, San Jose, CA) routers, one on each campus, manage data traffic transmitted between the two campuses. The audiometer used was an OTOPod from Otovation LLC (King of Prussia, PA) with TDH-39 earphones. Audiologist With Institutional Review Board approval, 25 volunteers were recruited to participate in the hearing tests. They had a mean age of 24 years, with a range of 20-60 years. All volunteers were college students and faculty in the School of Allied Health Sciences at East Carolina University. Medical and audiological histories were not known to the examining audiologists. The threshold procedure administered fol- lowed the American Speech-Hearing-Language Association (ASHA) guidelines¹5 for audiometric evaluation. Each subject received an auditory threshold assessment with two different audiometric systems under three different data exchange configurations. The subjects were blinded as to which configuration was being used in the assessment procedure. The 3 independent audiologists were also blinded as to the results from other testing. Both the ear and the order of testing were counterbalanced. Air conduction thresholds were assessed at octave steps from 250 to 8,000 Hz. For all of the testing sessions, six pure tone thresholds were obtained. For all tests, the subjects were seated. in a sound-treated room meeting the American National Standards Fig. 3. Current configuration of the prototyped distributed system. ECU, East Carolina University. ECU Intranet Institute (ANSI) S3.1-1991 standards. 16 The audiometer used in the tests was calibrated to ANSI S3.1-1996 standards. ¹7 Results The pure tone threshold findings obtained from the standard mode and the remote mode with the two Internet access configurations are summarized in Table 1. Although some differences exist among the three testing modes, results are still comparable at all frequencies. In order to further examine the interconnection among different testing modes, the results were further analyzed using a two-factor (testing conditions: standard, remote with gateway, and remote with computer; and tone frequencies) repetitive (25 observations, 1 from each subject) analysis of variance. Remote I As expected, the results demonstrated no significant differences in threshold findings between test approaches (df = 2, p = 0.6747 >> 0.05) thresholds are significantly different at various frequencies (df = 5, p Remote II ECU Science and Technology Building Table 1. Mean and Standard Deviation of Hearing Thresholds by Stimulus Frequency and Assessment Method FREQUENCY 250 500 1,000 2,000 4,000 8,000 Standard Server 2.35 2.64 5.89 5.03 3.23 2.94 1.47 3.82 7.35 11.17 Mean 5.8 3.99 3.61 7.12 10.99 16.77 SD 0.88 3.82 6.47 Mean 10.88 8.39 11.00 16.41 SD 3.63 2.5 3.12 5.47 5.12 SD, standard deviation. 2.5 6.05 5.31 9.06 12.81 Mean 8.26 9.86 18.88 SD = 0). The analysis of the findings validated the feasibility of replacing conventional "face-to-face" tests with the remote hearing tests using the distributed system. Note that, since the 3 audiologists who partici- pated in the project alternated the standard and the remote test modes, these results should accommodate interexaminer variations. Average completion time for testing sessions were also collected and compared between the three testing approaches. As shown in Figure 4, the average time for a standard test (3.72 minutes) is noticeably shorter than that of a remote test (6.45 minutes and 5.72 minutes for the two remote configurations with a wireless gateway device or computer used as the Internet access point). Although the two remote modes take a lon- ger time to complete a hearing test, collecting six pure tone thresholds in less than 7 minutes is acceptable. This difference between standard tests and those with remote modes was a result of a combination of factors: • Compared to the conventional mode, the audiologist needs to log into the system and connect to the remote device through the Internet before starting the hearing test. • Data communication between the devices connected to the Internet may make multiple attempts if a data packet cannot be successfully transmitted to the intended destination. A few other observations are worthy of mention: audiologists who are familiar with conventional hearing assessment software can oper- ate the user interface with minimal training. Survey results collected after the test demonstrated a high level of satisfaction and interests in adopting a similar system if commercial products are available. Testing time (min) Average testing time with the three conditions Remote w/ gateway Remote w/ computer Testing conditions Standard Fig. 4. Testing time comparison: the remote testing approaches versus standard testing approach. Discussion During tests with remote modes, although the patient and the audi- ologist were connected through the Internet in terms of signal trans- mission, they were actually situated in the same building. A great deal of coordination ensured smooth testing, which is a reminder that the coordination between the clinical professional site and a distant patient site will be challenging. Patient sites must be integrated into existing facilities where professional help is available, such as com- munity health centers or remote telemedicine centers. In addition, an online multimedia communication tool is crucial to make both sites synchronized. Existing videoconference and text messaging software should satisfy communication requirements and support interactions using signing language or instant messages between the two parties. The technologies utilized in this prototype can be extended to most audiology practices. The utilization of common technologies allows all these services to be integrated under the same umbrella and be imple- mented on an application server hosted by a third party IT agent. The introduction of this new model may result in the following benefits: • The separation of clinical practice from technical support/ser- vices removes the necessity of having technical personnel at the clinical professional site, facilitating its widespread adoption by hospitals and clinic service departments, especially private practices. The system can be expanded to include online scheduling, accounting, and reimbursement. The management software can be hosted by a third party agent, avoiding software installation on the operator's computer. • The audiometer's Bluetooth telemetry connection to the Internet can take two configurations, using a regular computer or dedi- cated access point device, providing the desired flexibility to the patient site. • The clinical professional site requires a regular Web page browser without any additional software installation to conduct hearing tests. In our tests, the system worked well with different versions of Internet Explorer (IE7 and IE 8), Firefox, and Tencent Traveler (TT) (Tencent Holdings, Ltd., China). Any Internet access devices, such as PCs, laptops, personal digital assistants, or cell phones, could possibly be used for this application, giving audiologists great flexibility in terms of working environment. The new system also brings the following considerations: • Trained personnel must be present at the remote site. • Licensure/regulatory laws in audiology vary between states as well as countries; thus, this must be considered. • Insurance reimbursement is not clearly defined and efforts need to continue in this area. In the current study, volunteers were mostly students in East Carolina University's Communication Sciences program. Although some volunteers had certain hearing impairments, they were not active clinical patients. To fully investigate the feasibility and pos- sible issues of the system, we plan to extend our tests to clinical environments and collect effectiveness data when the examiner and participant are located in different geographic locations. Continued efforts will also focus on using various Internet connections. In conclusion, our new system presents a promising approach to implement hearing healthcare to remote sites with little technology requirements at the remote site. Other aspects of the system may allow professionals to see more patients in a more efficient and less costly manner. Acknowledgment The authors thank Ms. Ellen Crowell and Ms. Jessica Pierce, both Ph.D. students in the Department of Communication Sciences and Disorders, for their help in data collection. We also want to thank the networking support staff in the College of Technology and Computer Science for their support with setting up and maintaining the appli- cation server. Disclosure Statement Authors Yao and Givens along with East Carolina University have a provisional patent pending regarding the system used in this study. No competing financial interests exist with author Wan. REFERENCES 1. Lin JC. Current developments in telemedicine. IEEE Eng Med Biol Magazine 1999;18:22-27. 2. Givens GD, Elangovan S. Internet Application to Tele-Audiology-"Nothin' but Net." Am J Audiol 2003;12:59-65. 3. Krumm M, Ribera J, Schmiedge J. Using a telehealth medium for objective hearing testing: Implications for supporting rural universal newborn hearing screening programs. Semin Hearing 2005;26:3-12. 4. Lancaster P, Krumm M, Ribera J, Klich R. Remote hearing screenings via telehealth in a rural elementary school. Am J Audiol 2008;17:114-122. 5. Choi JM, Lee HB, Park CS, Oh SH, Park KS. PC-based tele-audiometry. Telemed Je-Health 2007;13:501-508. 6. World Health Organization. Primary ear and hearing care training resource: Advanced level. Geneva: World Health Organization, 2006. 7. Cruickshanks KJ, Wiley TL, Tweed TS, et al. Prevalence of hearing loss in older adults in Beaver Dam, Wisconsin: the Epidemiology of Hearing Loss Study. Am J Epidemiol 1998;148:879-886. 8. Agrawal Y, Platz E, Niparko JK. Prevalence of hearing loss and differences by demographic characteristics among US adults, Data from the National Health and Nutrition Examination Survey, 1999-2004. Arch Intern Med 2008;168:1522-1530. 9. US Department of Commerce. Statistical abstract of the United States. 117th ed. Washington, DC: US Census Bureau, 1997. 10. Gates GA, Cooper JC Jr, Kannel WB, Miller NJ. Hearing in the elderly: The Framingham cohort, 1983-1985; part 1: basic audiometric test results. Ear Hear 1990;11:247-256. 11. Rueben D, Walsh K, Moore A, et al. Hearing loss in community-dwelling older persons: National prevalence data and identification using simple questions. J Am Geriatr Soc 1998;46:1008-1011. 12. Pioneers in Telemedicine Interview with COL Ron K. Poropatich, M.D. Telemed e-Health 2008;14:413-417. 13. Laird Technologies, "Bluetooth High Speed USB Adapter." Available at: http:// www.ezurio.com/products/highspeedusbadaptor/ (Last accessed 11, 2009). 14. SENA Technologies, Inc., "Bluetooth/IP Gateway for multi-port wireless connections, Parani 1000." Available a :http://www.sena.com/download/datasheets/ds_parani_ msp1000.pdf (Last accessed April 11, 2009). 15. American Speech-Language-Hearing Association (ASHA). Guidelines for manual pure-tone threshold audiometry. Rockville, MD, 2005. 16. American National Standards Institute. Maximum permissible ambient noise levels for audiometric test rooms (ANSI S3-1-1991). New York: ANSI, 1991. 17. American National Standards Institute. Specifications for audiometers (ANSI S3.6-1996). New York: ANSI, 1996. Address correspondence to: Jianchu Yao, Ph.D. Department of Engineering College of Technology and Computer Science East Carolina University Greenville, NC 27858 E-mail: Yaoj@ecu.edu Received: March 14, 2009 Accepted: May 1, 2009
Transcribed Image Text:A Web Services-Based Distributed System with Browser-Client Architecture to Promote Tele-audiology Assessment Jianchu Yao, Ph.D.,' Gregg D. Givens, Ph.D.,2 and Yongbo Wan, M.S.¹ ¹Department of Engineering, College of Technology and Computer Science and 2Department of Communication Sciences and Disorders, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina. Abstract The purpose of this research was to extend applications of the Internet and other telecommunication means to the assessment of hearing. The newly developed distributed system consists primarily of an application server and its database, and Web services under browser-server architec- ture to support remote hearing assessment. A pilot study was conducted: three independent audiologists assessed hearing of 25 subjects using testing approaches with different data communication configurations. Analysis of the results demonstrated the feasibility of replacing conven- tional "face-to-face" tests with the remote hearing tests using the distrib- uted system. Because of its distributed architecture, the present system supports a new service model and separates technical maintenance and clinical services. Consequently, the system shows great potential to benefit the clinical hearing care profession. Future research is planned to apply this system to medical facilities and for distance applications. Key words: telehealth, audiology Introduction t is generally believed that telehealth removes geographical bar- riers, transportation limitations, infrastructure deficiencies, and many other resource discrepancies. The healthcare sector has embraced the advancements of communication technologies since its first emergence in 1960s using several media including telephone, ORIGINAL RESEARCH DOI: 10.1089/tmj.2009.0031 facsimile, e-mail, videoconference, and Internet.¹ The communica- tions between the patient and the clinical professional are either unidirectional or bidirectional; data exchanged between the two ends are transmitted either real-time (synchronously) or store-and-forward (asynchronously), depending upon factors such as application needs, infrastructure availability, personnel preferences, and expenditure concerns. Applications of the Internet in the healthcare industry vary broadly from remote health status monitoring, disease diagnosis, treatment assessment, rehabilitation, and counseling. The introduc- tion of telecommunications to these healthcare services brings signif- icant benefits to traditionally underserved regions and populations. Many believe that the adoption of remote operations in medical areas progresses at a much slower pace than other industries such as manufacturing, entertainment, online shopping, and distance educa- tion. More importantly, within the healthcare sector, the embracing of new technology is not uniform among all medical disciplines. While specialties that mostly use images (e.g., dermatology) have seen invigorating successes in taking full advantage of the technology innovations, relatively few tele-audiology efforts have been reported on remote hearing assessment. Among these few, Givens, along with colleagues in the Telemedicine Center at East Carolina University, devised a system that enables remote hearing assessment over the Internet and pioneered the effort in the telehearing frontier.² Results collected with the prototype demonstrated that the remote mode can obtain performance comparable to that of the conventional in-person approach. Others such as Krumm et al. have targeted infant's hearing assessment and demonstrated that telepractice may help traditionally underserved rural populations. 3,4 A PC-based audiometer developed by Choi et al. utilized the sound card as the tone/speech generator and enabled audiometers to be easily connected to the Internet.5 The authors share a common view about the future potential of telehearing and believe that there are many more opportunities for MARY ANN LIEBERT, INC. . VOL. 15 NO. 8 • OCTOBER 2009 TELEMEDICINE and e-HEALTH 777 YAO ET AL. telehealth technologies to support the audiology profession. The justifications for this observation can be placed in three main areas: needs, underserved populations, and nature of hearing tests. • Needs: Hearing loss remains a significant contributor to the healthcare needs of the world's population. The World Health Organization stated that hearing loss doubled from 1995 to 2005.6 Cruickshanks et al. (1986) stated that hearing loss is the third most prevalent chronic condition in older Americans." Agrawal et al. (2008) state that in 2003-2004, 16.1% (29 million) of adults in America have hearing loss in frequencies important to the understanding of speech. Other studies find that 25%- 40% of the population aged 65 years or older have some degree of hearing impairment. ⁹-11 • Underserved populations: Many of the populations with hearing loss are underserved due to lack of audiology specialists in rural regions, which prevents delivery of hearing care, and unafford- able transportation costs due to the long driving distance, which is further worsened by the rising fuel prices.¹2 Realizing these challenges, the authors sought more suitable tech- nology to continue research and development along this direction. A re-examination of the previous system² identified a few improve- ment opportunities to broaden applications of the technology. These include the following: • Proprietary software for assessment and communication needs to be installed in the audiologist terminal computer. Software installation, like other computer mainte- nance work, introduces inconvenience to medical professionals and usually requires technical support. • Due to the implementation technology uti- lized, the prior system required direct con- nection between the patient and audiologist, allowing only one-to-one assessment ses- sions. Therefore, the audiologist would be required to establish separate connections before testing each patient. • The legacy audiometer uses a RS-232 serial port, a standard communication means that provides a limited data transmission rate. This may lead to future interoperability issues because of the emergence of the latest communication protocols such as USB, and fewer newly developed computer systems are equipped with an RS-232 connection. 778 TELEMEDICINE and e-HEALTH OCTOBER 2009 Server Patient Audiometer • In the prior system, results of hearing assessment were stored in the audiologist's computer, thus not allowing sharing of clinical or patient information data. With the rapid adoption of electri- cal medical records, data stored in standard, online-accessible databases are desired. This article presents recent research progress in tele-audiology at East Carolina University. The purpose of this research was to extend applications of the Internet and other telecommunication means to the assessment of hearing. The newly developed distributed system, primarily consisting of an application server and its database, sup- ports a new service model and benefits the clinical hearing care profession, in both private practices and hospitals. Materials and Methods Figure 1 illustrates the proposed system with the distributed architecture. The system consists of subsystems that may be geo- graphically located in three sites: the application server (and its database), the clinical professional site, and the patient site. The application server hosts business operational logics required to coordinate all the tasks and a database that stores patient informa- tion and testing results. The functional modules implemented on the server are scalable: the essential functions include hearing test and Wireless connection Wireless connection Internet Fig. 1. A distributed system for tele-audiology. Physician Wired connection Audiologist Wired connection Audiometer Patient

Question

This is not a graded or a writing assignment.

What do the researchers think this study contributes to

What are its limitations?

data storage; other optional modules include appointment sched-
uling, billing, and reimbursement. The associated database stores
patient information: patient demographics, medical records, family
history, insurance information, and so on. Some of this information
requires manual input (e.g., patient demographics); some is auto-
matically recorded by the system (e.g., hearing thresholds).
The patient site is where patient audiometric data are collected
and forwarded to the server through the Internet. The patient site,
equipped with an audiometer and an Internet access point, can be
constructed in a community care center, nursing home, school, or
patient home. The clinical professional site requires only an Internet
access device with Web browser software installed. For both the
patient and clinical professional sites, the Internet connection can
be wired or wireless. With this system configuration, a hearing test
can be conducted as long as both sides have access to the system
server. The system works literally the same way regardless of the
geographical locations of the patient and the clinical professions.
They can be as close as in the same building, or may be located on
two different continents.
The system software is designed with browser-server architec-
ture. Users (in this case, audiologists) access the Web services on
the server through a standard Internet browser. The server monitors
the presence of remote audiometers and provides a list of connected
audiometer devices for audiologist selection. The audiologist selects
the proper device from the list that is used by
their patient. To allow coordination between the
clinic professional site and the patient site when
preparing for hearing test sessions, communica-
tion means such as telephone or videoconference
is needed. Once the testing starts, the audiologist
operates the remote audiometer through "brows-
ing" the hearing test Web page and observes
patient responses as indicated by the Web page.
To allow possible future system expansion,
the application server is hosted on an IBM blade
server running a virtual datacenter operating
system ESX with 3.5 updates from VMware Inc.
(Palo Alto, CA). Currently, a virtual machine with
dual 3.4-GHz central processing units and 2-GB
randomly accessible memory is used as the server.
This configuration is equivalent to that of a typi-
cal PC. The virtual machine is set up as a Windows
2003 Pro Virtual Server (Microsoft, Redmond,
WA). Application software on the server is devel-
oped under the Microsoft .NET framework.
Home
+ Patent Information
+ Hearing Test
+ Hearing Test Results
Device Status
Left Right
Connector AA
|Stimulus|T||7
Mode PP
WEB SERVICES-BASED TELE-AUDIOLOGY SYSTEM
To avoid the issue of fat clients as opposed to thin clients as in cli-
ent/server software architecture, the system employed browser/client
architecture, where all the services were implemented on the server.
No application tasks are completed by the user terminal computer.
The user browser opens Web pages located on the server and all the
operations are achieved by the server. This was achieved by adopt-
ing Active Server Pages (ASP), a Web service programming method,
when developing the Web pages. ASP is a program that runs within
the Internet Information Services, a free component of the Windows
operating system. ASP eliminates the need for executing any applica-
tions on a user's terminal. Functions associated with the Web services
were implemented by calling functions programmed in C#. Figure 2
shows the hearing test page on the application server as an example.
For demonstration purposes, the database is also implemented on
the same physical machine as the application server. In real systems,
the database and the part of the program for application logics can
be physically separated for the purposes of maintenance convenience.
and affordability (separating database from application logics poten-
tially reduces the requirements on the server's computation power
and storage capacity). For the prototype, information stored in the
database can be largely divided into three categories: user manage-
ment, patient information, and test results. The database can (and.
is expected to) be expanded to include appointment scheduling,
accounting, insurance, reimbursement, and so on.
Home > Heanne Test
Current Patient
Execute Result
Get Device List
Device Sunchronization
Luft
Right
125
0
X
Frequency (Hz)
Actual Frequency
Level (db)
Actual Level
Connector
Stimulus
Mede
Patient ID 50
TestTime 3/2/2009 4:12:26 PM
OK
East Carolina University Tele-Hearing Test Center
www.Logout
OPOD-0707-0008
Stimulation Duration (1) 2
250
0
X
X
X
750
X
X
1000
-5
30
Stimule Left
Left
OP
Text Results
1500
Air Conduction OBone Conduction
Tone
ONBN
O Steady
Pulsed
Fig. 2. The hearing test page of the server site.
X
Name A Volunteer
Device: OPOD-0707-0039
Remote Chestlp: 150.216.56.7
2000
0
X
Copyright © Eart Carolina University 2008
3000
x
X
Air Conduction
Ⓒ Tone
O Steady
4000
-5
X
Stimate Right
Right
-1000
30
-5
X
D
OBone Conduction
ONBN
Pulsed
8000
0
X
YAO ET AL.
The patient site was implemented with two pos-
sible configurations, depending on the availability
of access point devices to the Internet. If a PC or
laptop is available, the audiometer can be con-
nected to the computer through an EZURIO (Laird
Technologies, St. Louis, MO) Bluetooth-USB adapt-
er¹³ and exchanges data with the application server
over the Internet. In cases where a computer is not
available at the test site, a wireless Bluetooth-IP
gateway device (Parani 1000, SENA Technologies,
San Jose, CA) can be used to bridge the audiom-
eter and the Internet.
The clinical effectiveness of the prototype sys-
tem was primarily evaluated from two perspec-
tives: (1) the agreement of the hearing threshold
findings obtained from the teletests to those from
the conventional tests; and (2) the amount of time
ECU Allied
Health Building
Patient
that is required to conduct hearing tests using the two testing modes.
In the current testing setup (Fig. 3), the subjects (audiometer via
access device) and the audiologists (using an Internet browsing
device) both access the Internet from a building on the medical
campus at East Carolina University and exchange data through the
application server located on the main campus. At the physical layer,
the two campuses are connected with 1 gigabit per second fiber
connections. Two Cisco (Cisco Systems, San Jose, CA) routers, one
on each campus, manage data traffic transmitted between the two
campuses. The audiometer used was an OTOPod from Otovation LLC
(King of Prussia, PA) with TDH-39 earphones.
Audiologist
With Institutional Review Board approval, 25 volunteers were
recruited to participate in the hearing tests. They had a mean age of 24
years, with a range of 20-60 years. All volunteers were college students
and faculty in the School of Allied Health Sciences at East Carolina
University. Medical and audiological histories were not known to the
examining audiologists. The threshold procedure administered fol-
lowed the American Speech-Hearing-Language Association (ASHA)
guidelines¹5 for audiometric evaluation. Each subject received an
auditory threshold assessment with two different audiometric systems
under three different data exchange configurations. The subjects were
blinded as to which configuration was being used in the assessment
procedure. The 3 independent audiologists were also blinded as to the
results from other testing. Both the ear and the order of testing were
counterbalanced. Air conduction thresholds were assessed at octave
steps from 250 to 8,000 Hz. For all of the testing sessions, six pure
tone thresholds were obtained. For all tests, the subjects were seated.
in a sound-treated room meeting the American National Standards
Fig. 3. Current configuration of the prototyped distributed system. ECU, East Carolina
University.
ECU
Intranet
Institute (ANSI) S3.1-1991 standards. 16 The audiometer used in the tests
was calibrated to ANSI S3.1-1996 standards. ¹7
Results
The pure tone threshold findings obtained from the standard mode
and the remote mode with the two Internet access configurations are
summarized in Table 1. Although some differences exist among the
three testing modes, results are still comparable at all frequencies.
In order to further examine the interconnection among different
testing modes, the results were further analyzed using a two-factor
(testing conditions: standard, remote with gateway, and remote with
computer; and tone frequencies) repetitive (25 observations, 1 from
each subject) analysis of variance.
Remote I
As expected, the results demonstrated no significant differences in
threshold findings between test approaches (df = 2, p = 0.6747 >> 0.05)
thresholds are significantly different at various frequencies (df = 5, p
Remote II
ECU Science and
Technology Building
Table 1. Mean and Standard Deviation of Hearing Thresholds
by Stimulus Frequency and Assessment Method
FREQUENCY 250 500 1,000 2,000 4,000 8,000
Standard
Server
2.35 2.64
5.89
5.03
3.23 2.94 1.47 3.82 7.35 11.17 Mean
5.8 3.99 3.61 7.12 10.99 16.77 SD
0.88 3.82 6.47
Mean
10.88
8.39 11.00 16.41 SD
3.63
2.5
3.12
5.47 5.12
SD, standard deviation.
2.5
6.05
5.31
9.06 12.81
Mean
8.26 9.86 18.88 SD
= 0). The analysis of the findings validated the feasibility of replacing
conventional "face-to-face" tests with the remote hearing tests using
the distributed system. Note that, since the 3 audiologists who partici-
pated in the project alternated the standard and the remote test modes,
these results should accommodate interexaminer variations.
Average completion time for testing sessions were also collected and
compared between the three testing approaches. As shown in Figure 4,
the average time for a standard test (3.72 minutes) is noticeably shorter
than that of a remote test (6.45 minutes and 5.72 minutes for the two
remote configurations with a wireless gateway device or computer used
as the Internet access point). Although the two remote modes take a lon-
ger time to complete a hearing test, collecting six pure tone thresholds in
less than 7 minutes is acceptable. This difference between standard tests
and those with remote modes was a result of a combination of factors:
• Compared to the conventional mode, the audiologist needs to log
into the system and connect to the remote device through the
Internet before starting the hearing test.
• Data communication between the devices connected to the
Internet may make multiple attempts if a data packet cannot be
successfully transmitted to the intended destination.
A few other observations are worthy of mention: audiologists who
are familiar with conventional hearing assessment software can oper-
ate the user interface with minimal training. Survey results collected
after the test demonstrated a high level of satisfaction and interests in
adopting a similar system if commercial products are available.
Testing time (min)
Average testing time with the three conditions
Remote w/
gateway
Remote w/
computer
Testing conditions
Standard
Fig. 4. Testing time comparison: the remote testing approaches
versus standard testing approach.
Discussion
During tests with remote modes, although the patient and the audi-
ologist were connected through the Internet in terms of signal trans-
mission, they were actually situated in the same building. A great
deal of coordination ensured smooth testing, which is a reminder that
the coordination between the clinical professional site and a distant
patient site will be challenging. Patient sites must be integrated into
existing facilities where professional help is available, such as com-
munity health centers or remote telemedicine centers. In addition, an
online multimedia communication tool is crucial to make both sites
synchronized. Existing videoconference and text messaging software
should satisfy communication requirements and support interactions
using signing language or instant messages between the two parties.
The technologies utilized in this prototype can be extended to most
audiology practices. The utilization of common technologies allows all
these services to be integrated under the same umbrella and be imple-
mented on an application server hosted by a third party IT agent. The
introduction of this new model may result in the following benefits:
• The separation of clinical practice from technical support/ser-
vices removes the necessity of having technical personnel at
the clinical professional site, facilitating its widespread adoption
by hospitals and clinic service departments, especially private
practices.
The system can be expanded to include online scheduling,
accounting, and reimbursement. The management software can
be hosted by a third party agent, avoiding software installation
on the operator's computer.
• The audiometer's Bluetooth telemetry connection to the Internet
can take two configurations, using a regular computer or dedi-
cated access point device, providing the desired flexibility to the
patient site.
• The clinical professional site requires a regular Web page browser
without any additional software installation to conduct hearing
tests. In our tests, the system worked well with different versions
of Internet Explorer (IE7 and IE 8), Firefox, and Tencent Traveler
(TT) (Tencent Holdings, Ltd., China). Any Internet access devices,
such as PCs, laptops, personal digital assistants, or cell phones,
could possibly be used for this application, giving audiologists
great flexibility in terms of working environment.
The new system also brings the following considerations:
• Trained personnel must be present at the remote site.
• Licensure/regulatory laws in audiology vary between states as
well as countries; thus, this must be considered.
• Insurance reimbursement is not clearly defined and efforts need
to continue in this area.
In the current study, volunteers were mostly students in East
Carolina University's Communication Sciences program. Although
some volunteers had certain hearing impairments, they were not
active clinical patients. To fully investigate the feasibility and pos-
sible issues of the system, we plan to extend our tests to clinical
environments and collect effectiveness data when the examiner and
participant are located in different geographic locations. Continued
efforts will also focus on using various Internet connections.
In conclusion, our new system presents a promising approach to
implement hearing healthcare to remote sites with little technology
requirements at the remote site. Other aspects of the system may
allow professionals to see more patients in a more efficient and less
costly manner.
Acknowledgment
The authors thank Ms. Ellen Crowell and Ms. Jessica Pierce, both
Ph.D. students in the Department of Communication Sciences and
Disorders, for their help in data collection. We also want to thank the
networking support staff in the College of Technology and Computer
Science for their support with setting up and maintaining the appli-
cation server.
Disclosure Statement
Authors Yao and Givens along with East Carolina University have
a provisional patent pending regarding the system used in this study.
No competing financial interests exist with author Wan.
REFERENCES
1. Lin JC. Current developments in telemedicine. IEEE Eng Med Biol Magazine
1999;18:22-27.
2. Givens GD, Elangovan S. Internet Application to Tele-Audiology-"Nothin'
but Net." Am J Audiol 2003;12:59-65.
3. Krumm M, Ribera J, Schmiedge J. Using a telehealth medium for objective
hearing testing: Implications for supporting rural universal newborn hearing
screening programs. Semin Hearing 2005;26:3-12.
4. Lancaster P, Krumm M, Ribera J, Klich R. Remote hearing screenings via
telehealth in a rural elementary school. Am J Audiol 2008;17:114-122.
5. Choi JM, Lee HB, Park CS, Oh SH, Park KS. PC-based tele-audiometry.
Telemed Je-Health 2007;13:501-508.
6. World Health Organization. Primary ear and hearing care training resource:
Advanced level. Geneva: World Health Organization, 2006.
7. Cruickshanks KJ, Wiley TL, Tweed TS, et al. Prevalence of hearing loss in older
adults in Beaver Dam, Wisconsin: the Epidemiology of Hearing Loss Study.
Am J Epidemiol 1998;148:879-886.
8. Agrawal Y, Platz E, Niparko JK. Prevalence of hearing loss and differences
by demographic characteristics among US adults, Data from the National
Health and Nutrition Examination Survey, 1999-2004. Arch Intern Med
2008;168:1522-1530.
9. US Department of Commerce. Statistical abstract of the United States.
117th ed. Washington, DC: US Census Bureau, 1997.
10. Gates GA, Cooper JC Jr, Kannel WB, Miller NJ. Hearing in the elderly:
The Framingham cohort, 1983-1985; part 1: basic audiometric test results.
Ear Hear 1990;11:247-256.
11. Rueben D, Walsh K, Moore A, et al. Hearing loss in community-dwelling older
persons: National prevalence data and identification using simple questions.
J Am Geriatr Soc 1998;46:1008-1011.
12. Pioneers in Telemedicine Interview with COL Ron K. Poropatich, M.D.
Telemed e-Health 2008;14:413-417.
13. Laird Technologies, "Bluetooth High Speed USB Adapter." Available at: http://
www.ezurio.com/products/highspeedusbadaptor/ (Last accessed 11, 2009).
14. SENA Technologies, Inc., "Bluetooth/IP Gateway for multi-port wireless connections,
Parani 1000." Available a :http://www.sena.com/download/datasheets/ds_parani_
msp1000.pdf (Last accessed April 11, 2009).
15. American Speech-Language-Hearing Association (ASHA). Guidelines for manual
pure-tone threshold audiometry. Rockville, MD, 2005.
16. American National Standards Institute. Maximum permissible ambient noise
levels for audiometric test rooms (ANSI S3-1-1991). New York: ANSI, 1991.
17. American National Standards Institute. Specifications for audiometers
(ANSI S3.6-1996). New York: ANSI, 1996.
Address correspondence to:
Jianchu Yao, Ph.D.
Department of Engineering
College of Technology and Computer Science
East Carolina University
Greenville, NC 27858
E-mail: Yaoj@ecu.edu
Received: March 14, 2009
Accepted: May 1, 2009

A Web Services-Based Distributed System
with Browser-Client Architecture to
Promote Tele-audiology Assessment
Jianchu Yao, Ph.D.,' Gregg D. Givens, Ph.D.,2 and Yongbo Wan, M.S.¹
¹Department of Engineering, College of Technology and Computer
Science and 2Department of Communication Sciences and Disorders,
College of Allied Health Sciences, East Carolina University, Greenville,
North Carolina.
Abstract
The purpose of this research was to extend applications of the Internet
and other telecommunication means to the assessment of hearing. The
newly developed distributed system consists primarily of an application
server and its database, and Web services under browser-server architec-
ture to support remote hearing assessment. A pilot study was conducted:
three independent audiologists assessed hearing of 25 subjects using
testing approaches with different data communication configurations.
Analysis of the results demonstrated the feasibility of replacing conven-
tional "face-to-face" tests with the remote hearing tests using the distrib-
uted system. Because of its distributed architecture, the present system
supports a new service model and separates technical maintenance
and clinical services. Consequently, the system shows great potential to
benefit the clinical hearing care profession. Future research is planned
to apply this system to medical facilities and for distance applications.
Key words: telehealth, audiology
Introduction
t is generally believed that telehealth removes geographical bar-
riers, transportation limitations, infrastructure deficiencies, and
many other resource discrepancies. The healthcare sector has
embraced the advancements of communication technologies since
its first emergence in 1960s using several media including telephone,
ORIGINAL RESEARCH
DOI: 10.1089/tmj.2009.0031
facsimile, e-mail, videoconference, and Internet.¹ The communica-
tions between the patient and the clinical professional are either
unidirectional or bidirectional; data exchanged between the two ends
are transmitted either real-time (synchronously) or store-and-forward
(asynchronously), depending upon factors such as application needs,
infrastructure availability, personnel preferences, and expenditure
concerns. Applications of the Internet in the healthcare industry vary
broadly from remote health status monitoring, disease diagnosis,
treatment assessment, rehabilitation, and counseling. The introduc-
tion of telecommunications to these healthcare services brings signif-
icant benefits to traditionally underserved regions and populations.
Many believe that the adoption of remote operations in medical
areas progresses at a much slower pace than other industries such as
manufacturing, entertainment, online shopping, and distance educa-
tion. More importantly, within the healthcare sector, the embracing
of new technology is not uniform among all medical disciplines.
While specialties that mostly use images (e.g., dermatology) have seen
invigorating successes in taking full advantage of the technology
innovations, relatively few tele-audiology efforts have been reported
on remote hearing assessment. Among these few, Givens, along with
colleagues in the Telemedicine Center at East Carolina University,
devised a system that enables remote hearing assessment over the
Internet and pioneered the effort in the telehearing frontier.² Results
collected with the prototype demonstrated that the remote mode can
obtain performance comparable to that of the conventional in-person
approach. Others such as Krumm et al. have targeted infant's hearing
assessment and demonstrated that telepractice may help traditionally
underserved rural populations. 3,4 A PC-based audiometer developed
by Choi et al. utilized the sound card as the tone/speech generator
and enabled audiometers to be easily connected to the Internet.5
The authors share a common view about the future potential of
telehearing and believe that there are many more opportunities for
MARY ANN LIEBERT, INC. . VOL. 15 NO. 8 • OCTOBER 2009 TELEMEDICINE and e-HEALTH 777
YAO ET AL.
telehealth technologies to support the audiology profession. The
justifications for this observation can be placed in three main areas:
needs, underserved populations, and nature of hearing tests.
• Needs: Hearing loss remains a significant contributor to the
healthcare needs of the world's population. The World Health
Organization stated that hearing loss doubled from 1995 to
2005.6 Cruickshanks et al. (1986) stated that hearing loss is the
third most prevalent chronic condition in older Americans."
Agrawal et al. (2008) state that in 2003-2004, 16.1% (29 million)
of adults in America have hearing loss in frequencies important
to the understanding of speech. Other studies find that 25%-
40% of the population aged 65 years or older have some degree
of hearing impairment. ⁹-11
• Underserved populations: Many of the populations with hearing
loss are underserved due to lack of audiology specialists in rural
regions, which prevents delivery of hearing care, and unafford-
able transportation costs due to the long driving distance, which
is further worsened by the rising fuel prices.¹2
Realizing these challenges, the authors sought more suitable tech-
nology to continue research and development along this direction.
A re-examination of the previous system² identified a few improve-
ment opportunities to broaden applications of the technology. These
include the following:
• Proprietary software for assessment and
communication needs to be installed in the
audiologist terminal computer. Software
installation, like other computer mainte-
nance work, introduces inconvenience to
medical professionals and usually requires
technical support.
• Due to the implementation technology uti-
lized, the prior system required direct con-
nection between the patient and audiologist,
allowing only one-to-one assessment ses-
sions. Therefore, the audiologist would be
required to establish separate connections
before testing each patient.
• The legacy audiometer uses a RS-232 serial
port, a standard communication means that
provides a limited data transmission rate.
This may lead to future interoperability
issues because of the emergence of the latest
communication protocols such as USB, and
fewer newly developed computer systems are
equipped with an RS-232 connection.
778 TELEMEDICINE and e-HEALTH OCTOBER 2009
Server
Patient
Audiometer
• In the prior system, results of hearing assessment were stored in
the audiologist's computer, thus not allowing sharing of clinical
or patient information data. With the rapid adoption of electri-
cal medical records, data stored in standard, online-accessible
databases are desired.
This article presents recent research progress in tele-audiology at
East Carolina University. The purpose of this research was to extend
applications of the Internet and other telecommunication means to
the assessment of hearing. The newly developed distributed system,
primarily consisting of an application server and its database, sup-
ports a new service model and benefits the clinical hearing care
profession, in both private practices and hospitals.
Materials and Methods
Figure 1 illustrates the proposed system with the distributed
architecture. The system consists of subsystems that may be geo-
graphically located in three sites: the application server (and its
database), the clinical professional site, and the patient site. The
application server hosts business operational logics required to
coordinate all the tasks and a database that stores patient informa-
tion and testing results. The functional modules implemented on the
server are scalable: the essential functions include hearing test and
Wireless
connection
Wireless
connection
Internet
Fig. 1. A distributed system for tele-audiology.
Physician
Wired
connection
Audiologist
Wired
connection Audiometer
Patient

Accepted Answer

The provided text presents a case report investigating the feasibility and effectiveness of…