Speech-Language Pathology and Audiology in South Africa: Clinical Training and Service in the Era of COVID-19

Introduction and purpose: The novel coronavirus (COVID-19) presented new and unanticipated challenges to the provision of clinical services, from student training to the care of patients with speech-language and hearing (SLH) disorders. Prompt changes in information and communication technologies (ICT), were required to ensure that clinical training continued to meet the Health Professions Council of South Africa's regulations and patients received effective clinical care. The purpose of this study was to investigate online clinical training and supervision to inform current and future training and clinical care provision in SLH professions. Methodology: A scoping review was conducted using the Arksey and O’Malley (2005) framework. The electronic bibliographic databases Science Direct, PubMed, Scopus, MEDLINE, and ProQuest were searched to identify publications about online clinical training and supervision and their impact on clinical service during COVID-19. Selection and analysis were performed by three independent reviewers using pretested forms. Results and Conclusions: The findings revealed important benefits of teletraining and telepractice with potential application to South African clinical training and service provision. Five themes emerged: (1) practice produces favorable outcomes, (2) appreciation for hybrid models of training and service delivery, (3) cost effectiveness is a “big win” (4) internationalization of remote clinical training and service provision, and (5) comparable modality outcomes. These findings may have significant implications for teletraining and telepractice in low-and-middle income countries (LMICs) in the COVID-19 era and beyond, wherein demand versus capacity challenges (e.g., in human resources) persist. Current findings highlight the need for SLH training programmes to foster a hybrid clinical training model. Few studies were conducted in LMICs, indicating a gap in such research.


METHODOLOGY
Adhering to the methodology advocated by Levac et al. (2010), the research team was comprised of three researchers working in academia in the fields of speech-language pathology and audiology. They agreed upon the research question, the search terms, keywords, and phrases to be searched, and the searchable databases. The researchers adopted the Arksey and O'Malley's (2005) five phased framework: (1) identifying the research question, (2) identifying relevant publications, (3) study selection, (4) charting the data and (5) collating, summarizing, and reporting the results.

RESEARCH QUESTION
This review explored the question: 'Is telepractice useful for clinical training and clinical service delivery?' This question was guided by the increasing need for the use of ICT globally in all sectors of societies -particularly within healthcare delivery. COVID-19 accelerated the use of telehealth as a strategy to lessen the pandemic's spread. The researchers reviewed the available evidence to identify barriers for teletraining and telepractice within the South African SLH professions. Furthermore, influenced by Daudt et al. (2013) on the value of scoping reviews, the current review revealed the types and sources of evidence available on the above-mentioned question. All of the reviews would have implications for clinical training, clinical practice, the drafting of policy and regulations, and future research.

DATA SOURCES AND SEARCH STRATEGY
The initial search was carried out in September 2020 in the following five electronic databases: Science Direct, PubMed, Scopus, Medline, and ProQuest. The databases were selected as they were deemed to be comprehensive and included publications on the use of telepractice for clinical training and SLH service delivery. The selected studies were restricted to those published in English from the year 2010 onwards, with a focus on these two specific scopes of practice: training/supervision and practice. The search consisted of the following terms: practitioner, clinician, doctor, therapist, supervision, education, telehealth, telepractice, online learning, online training, and telemedicine.

RESOURCES
Forty-two citations were subsequently included in the analysis (see Appendix). An additional search of the aforementioned bibliographic databases was conducted in November 2020 to ensure that any additional publications post the initial search were also identified. No new publications were identified.

CITATION MANAGEMENT
Citations were imported into the web-based bibliographic manager Endnote. A manual removal of duplicate citations was conducted using the Endnote functionality of identifying duplicates.

ELIGIBILITY CRITERIA
The researchers adopted a two-stage screening process to evaluate the applicability of publications identified in the search. The first stage involved the inclusion of publications that contained the keywords and phrases and those broadly describing telepractice in clinical training and clinical practice. In the second stage, publications were excluded that described telepractice in areas other than healthcare; however, the reference lists from these publications were reviewed to identify additional relevant publications. Owing to limited resources for translation, only English publications were included.

TITLE AND ABSTRACT RELEVANCE SCREENING
As recommended by Arksey and O'Malley (2005): (1) the first level review examined the titles of the manuscripts; (2) the second level review examined abstracts; and (3) the third level review included entire articles (refer to Figure 1). This process eliminated articles that did not meet the study's minimum inclusion criteria. The researchers used a previously developed and pretested abstract relevance screening spreadsheet, which had been found to have high level reviewer agreement (overall kappa) greater than 0.8 (Viera & Garrett, 2005). The titles, abstracts, and entire articles were independently screened by the three researchers, with a process set up to ensure triangulation during the process of data selection and analysis. When an abstract was not available, the article underwent a full article review. The researchers communicated online to ensure that conflicts were resolved, with one author (NM) making the final decision to resolve disagreements. A high level of agreement was found with the overall kappa of 0.83. Following the data analysis, two independent reviewers (i.e., a PhD fellow and a postdoc fellow), reviewed the manuscript and the data to validate the authors' conclusions.

DATA CHARACTERISATION
Following the title and abstract inspection, relevant citations about telepractice in clinical training and clinical practice were extracted for later full publication reviews. The relevance of the publication was confirmed and details of the publication were recorded on a spreadsheet (i.e., author and publication year, publication title, context, clinical training versus clinical service provision, and outcomes/considerations/ recommendations). The characteristics of each publication were recorded by all three researchers. Additional publications were excluded if they did not meet the minimum eligibility criteria. In adherence with Levac et al.'s (2010) framework, the researchers performed independent reviews, resolved any conflicts, and ensured consistency.

DATA SUMMARY AND SYNTHESIS
The data were compiled in a single spreadsheet and imported into Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA, USA) for descriptive narrative analysis.
A total of 16,174 studies were identified for potential analysis. In the process of collating and organising the studies, 12,795 duplicate studies were removed; thus, only 3,379 studies were considered. Of the 3,379 remaining studies, 3,251 were excluded based on the titles and/or abstracts. Consequently, 128 studies were assessed for eligibility; from these 86 were excluded as they did not meet the inclusion criteria for the current study. Finally, 42 studies were included for analysis in the current study (see Figure 1).

ETHICAL CONSIDERATIONS
This research followed all ethical standards for studies without direct contact with human or animal subjects, including informed subjectivity and reflexivity, purposefully informed selective inclusivity, and audience-appropriate transparency (Suri, 2020).

RESULTS AND DISCUSSION
Findings of the current review indicated an increasing use of teletraining and telepractice internationally, with very limited evidence from Africa, and/or LMICs. Studies found in these LMIC regions included those from Sri Lanka, various states across India, and Kenya (see Appendix). There was an unequal distribution between studies focusing on clinical training (26 studies) and those focusing on clinical service provision through tele-modalities (16 studies). Qualitative analysis of the studies revealed the emergence of five themes.
That limited research has been conducted on teletraining and telepractice in Africa was a significant finding; this underscored the need to accelerate the focus on these service delivery methods to increase access for both students and patients within a capacity challenged region. The heavy reliance on one-on-one, in-person direct training and/or clinical service provision was a significant drawback under normal circumstances and has been even worse during the COVID-19 pandemic.
Only one study (Carrick et al., 2017) commented on gender differences wherein women were reported to cope better with in-person learning than their male counterparts. The influence of gender on online learning is an important factor to consider as some studies have reported gender differences in online participation (Morante et al., 2017;Selwyn, 2007;Yaghmour, 2012;Yoo & Huang, 2013).
The themes that emerged from the evidence reviewed include: (1) Practice makes perfect, (2) the value of hybrid models of training and service delivery, (3) telepractice is cost-effective (4) internalization of remote clinical training and service provision, and (5) comparable modality outcomes.

PRACTICE MAKES PERFECT
In-person treatment was perceived as effective and most preferred, pre-COVID19, followed by video service delivery. Audio only delivery was the least effective, though usable (Blumenthal et al., 2014;Martin et al., 2012). In contrast, during pandemic outbreaks, in-person learning in a physical classroom may not be possible (Mpungose, 2020).
In the current study, remote learning was reportedly less intimidating for students, health practitioners, and end-users as it allowed for greater control of the environment (Howells et al., 2019;Karaksha et al., 2013;Martin et al., 2012). These findings were confirmed by Hassenburg (2009) who asserted that, while there are benefits to being physically present and interacting with a human teacher, remote learning allows freedoms and benefits that were not previously imagined. These benefits include access for learners with disabilities and those in rural areas; cost effectiveness, convenience and flexibility; as well as ease of holding online discussions with the flexibility to pause and rewind (Hassenburg, 2009). Furthermore, remote learning allows for the training and/or clinical service provision to be performed at a pace that can be adjusted to the needs of the students and patients (Forde & Gallagher, 2020;Grewal et al., 2020;Langkamp et al., 2015;Muflih et al., 2020;Tariq et al., 2018) . Moreover, in the current review telepractice services were accepted by stakeholders and students with a high satisfaction rate (Batthish et al., 2013;Cassel & Edd, 2016;Giudice et al., 2015;Langkamp et al., 2015;Likic et al., 2013;Lincoln et al., 2014;Walsh et al., 2011). Wagner et al. (2006) argued that the success of remote learning or remote interaction is dependent on the stakeholders' satisfaction in meeting and addressing their needs and concerns. Similarly, Ramaswamy et al. (2020) reported patient satisfaction with video visits when compared to traditional in-person clinic visits.
Arguably, the process may initially be challenging, practice produces favorable results, particularly with regard to technology and administrative support, and the training of users on the ICT (Cameron et al., 2015;Likic et al., 2013). According to Meyer and Barefield (2010) administrative support is the vital foundation to a sound online education program. Similarly, the success of online learning is dependent on the skills and quality of technical support to users, without which, the ability of teachers and students to use technology will be compromised (Nawaz & Khan, 2012). The training of the sitefacilitator and/or patient/caregiver is also crucial to the success of the telepractice interaction. Concerns regarding technology were also revealed in this review (Bredfeldt et al., 2013;Langkamp et al., 2015;Lincoln et al., 2014). For instance, Lincoln et al. (2014) reported that the use of technology within the school environment increased the complexities of service delivery. However, these challenges can be mitigated by ensuring sound administrative and technology support. Goehring et al. (2012) reported that the effectiveness of remote learning and service provision is negatively impacted by limitations in technology. Therefore, the influence of technology to the success and/or failure of teletraining and telepractice cannot be overemphasized. This is consequential more so, in the initial stages, when blended learning may be used to facilitate the move to remote learning, as some end-users may not be savvy with technology.

HYBRID TRAINING AND SERVICE DELIVERY MODELS ARE VALUABLE
The current review revealed that hybrid models (blended approaches) of clinical training, (e.g., training using e-learning to teach theoretical aspects and experiential learning for students to develop practical skills), and clinical service provision, (e.g., clinical care e-training for information counselling and therapy where physical manipulation is not required -with experiential clinical care for physical demonstration) are appreciated (Edirippulige et al., 2012). Bredfeldt et al. (2013) conducted a study to improve providers' effectiveness with electronic health records through blended learning, integrating concrete scenarios, hands-on exercises, and take-home materials to reinforce class concepts. The findings confirmed the value of using blended/hybrid learning as the training was well-received and for which the participants expressed a clear preference. Similarly, Guiberson et al. (2015) provided preliminary evidence on the effectiveness of a hybrid telehealth model in screening language development in children, while Chin et al. (2021) concluded that the hybrid curriculum is an innovative way to maximize learning opportunities while maintaining social distancing in the COVID-19 pandemic era.
The benefits of using hybrid models for learning have also been discussed by authors such as Hall and Villareal (2015) who documented student satisfaction with hybrid courses. This satisfaction was based on the convenience, engagement, ability to work at one's own pace, as well as comfort in expressing views. Paechter and Maier (2010) enumerated five factors associated with student satisfaction with hybrid learning: (a) clarity and structure, (b) knowledge acquisition, (c) the instructor's online expertise, (d) support from the instructor, and (e) support for cooperative learning. Esmail et al. (2009) recommend that more training in the use of technology as well as recording synchronous sessions for later review are important, as these will enhance and motivate students to engage more meaningfully. Related to motivation, the Karaksha et al. (2013) study included in the current review highlighted the need for incentivizing strategies (i.e., marketing strategies) such as emails, short message service (SMS), WhatsApp, and such, to remind and motivate learners to engage with online material and learning. When implementing online clinical training, clinical service training and marketing strategies, there should be careful consideration of the cost-effectiveness of providing such services, and interactions with funders need to occur to ensure that support is provided to patients, where needed.

COST EFFECTIVENESS IS A "BIG WIN"
The majority of the studies highlighted cost effectiveness as one of the significant benefits of remote clinical training and service provision (Carrick et al., 2017;Chandrasinghe et al., 2020;Goehring et al., 2012;Harris & Sun, 2013;Likic et al., 2013;Thomas et al., 2021). Cost effectiveness was realized in different forms including travel time and expenses, demand versus capacity of staff and clinicians, and safe access environments. Evans and Haase (2001) discussed the benefits of remote learning; these included greater impact of money invested in training programs (i.e., value for money); significantly reduced employee travel cost and time; and the capacity to train more people (e.g., students) more often and in shorter sessions that are easier to coordinate and schedule. These benefits can easily transfer to clinical service provision and supervision. However, one study by Moffatt and Eley (2011) concluded that telehealth is not only not cost effective, but is not a rational response as it has implications for policy, funding priorities and education and training. This is a key consideration in LMICs as resources are not easily available due to finances and poor infrastructure. To this effect, Muttiah et al. (2016) noted that LMICs have a large rural population; limited health, education and technology resources; and have a poorly performing economy. Therefore, careful attention to these factors is necessary. Sagna (2005) cautions that, although remote learning is effective in high income countries, its success in LMICs requires supplements due to poor infrastructure including limited telephone connections, poor internet bandwidth, shortage of trained personnel and limited computer skills among users.
Despite these barriers to remote learning in LMICs, current trends in Sub-Saharan Africa show that remote learning is on the rise despite persistent technological challenges. In fact, remote learning is perceived as a rational, cost-effective means to widen educational opportunities (Trines, 2018). Regarding remote service provision, Zhang and Zaman (2020) assert that telemedicine can be an efficient and cost-effective solution to address health concerns such as diagnosis and treatment of patients in remote locations. Use of a variety of information and communication technologies can minimize the difficulties and costs of traveling, save time, and provide rural populations with access to resources that are comparable to those of patients in urban areas. The current authors argue that the cost effectiveness benefits of telepractice and teletraining extends to the adoption of family-centred interventions, which have been documented to be more efficacious, especially in early intervention in SLH, wherein families can become part of the interventions without the travel costs that ordinarily prevent them from this important healthcare involvement (Maluleke et al., 2021).

INTERNATIONALIZATION OF REMOTE CLINICAL TRAINING AND SERVICE PROVISION
Internationalizing higher education is a major goal for universities as many medical students aspire to include international experiences into their academic training (Knipper et al., 2015), and remote learning affords such opportunities. Internationalization is a significant benefit both for student training and clinical service provision. In this review, Likic et al. (2013) asserted that online teaching resources can be translated and implement internationally, and still achieve high student satisfaction rates, while decreasing administrative and cost burdens. Hansen et al. (2020) provided evidence for the feasibility of developing a multifaceted web-wide training programme for an international trial, while Cassel and Edd (2016) reported a high degree of satisfaction and improved familiarity with the use of telepractice, and an increased comfort level working with multi-cultural populations. Internationalization has benefits such as quality improvement, provision of access, competitiveness, financial profits, and the provision of a professionally relevant education that prepares all students to be interculturally proficient professionals and citizens (Wu et al., 2020). However, it may also result in unintended consequences such as ethical dilemmas. Based on the studies included in this review, it is evident that internationalization provides significant benefits both in student training and clinical service provision. However, the contextual relevance and responsiveness that are important in remote interventions (i.e., linguistic and cultural diversity issues, teaching and/or treatment, and use of multimedia options) must be carefully considered when implementing such services. Khoza-Shangase and Sebothoma (in press) argue that in South African SLH professions, internationalization can include access to the international SLH community for student clinical supervision in training platforms that are far removed from the university campuses where full-time staff are placed -and where demand-capacity challenges exist in student to staff ratios. This internationalization also has potential for the South African training programmes to provide training in the rest of Africa, where SLH training is not yet available.

COMPARABLE MODALITY OUTCOMES
The outcomes of remote clinical teaching and clinical remote learning should mirror and match the outcomes expected from in-person training and service provision. In the current review, Berland et al. (2019) conducted a comparative analysis of online learning vs in-person training. In evaluating the educational outcomes, these authors did not find a meaningful or significant difference between in-person training and online learning. These authors concluded that online modules could provide a sustainable, convenient, and engaging approach to facilitate dissemination of lifesaving training. Similarly, Dial et al.  (2019) have reported similar findings where they found no significant difference in performance between online and traditional classroom teaching with respect to modality (online vs in-person), gender, or class rank. Interestingly, Kirovska-Simjanoska (2019) concluded that students learn better through a combination of an online and traditional classroom -a hybrid model.

CONCLUSIONS AND RECOMMENDATIONS
Clinical training and clinical service provision in the era of COVID-19 required innovative models of service delivery to ensure the health and safety of patients, clinicians, and students, as well as uninterrupted service. The use of alternative service delivery models, including teletraining and telepractice required exploring, hence the current review. This study identified 42 papers that met the predefined inclusion criteria for a scoping review. The studies that were selected were heterogeneous; therefore, attempts were not made to conduct a quantitative synthesis or meta-analysis. Nonetheless, the qualitative analysis yielded clear trends indicating the potential benefits of teletraining and telepractice under five themes.
Firstly, under "practice makes perfect," one can conclude that training on the use of ICT as a platform is key to ensuring success and sustainability of this service delivery model. Within the African context, where task-shifting may form part of this model for clinical service provision, minimum standards of training including ICT training is important.
Secondly, under "appreciation for hybrid models of training and service delivery," evidence suggests that carefully planned and executed training and clinical service that is blended and/or hybrid allows for flexibility and takes careful cognizance of diversity in learning style preferences as well as diversity in access and opportunities. It is important though that costs linked to this hybrid model are carefully considered and do not present as a barrier for those who do not have access to ICT infrastructure and resources, such as data.
Thirdly, as far as the "cost-effectiveness is a big win" theme is concerned, the risks-benefits evaluation of telepractice and teletraining seem to indicate more cost-effectiveness. This should be carefully considered for universal health coverage in LMICs where socio-economic challenges are significant for the population requiring access to healthcare; similarly, with those needing access to higher education.
Fourthly, under the "internationalization of remote clinical training and service provision" theme, access to clinical care as well as clinical training from the international community, as well as expanding and extending these services to the rest of Africa via e-learning and e-training is a significant benefit that needs to be explored. The analysis must bear in mind policies and regulations around internationalization in the country of origin as well as in the country of the receiver of the services. Regulations around healthcare training and delivery as well as ethical and professional codes of conduct need to be adhered to in order to ensure that professions are guided while patients are protected; as illustrated by the Health Professions Council of South Africa's mandate, for example.
Lastly, evidence under the theme "comparable modality outcomes" highlights the fact that online, teletraining, and telepractice seem to compare favourably to direct in-person delivery and/or interventions; this is a positive finding. However, the fact that better outcomes were observed in hybrid models indicates a need to explore that further, to determine factors that enhance and/or impede each model of service delivery. In SLH professions, for example, it is anticipated that equipment used for assessment and management synchronously or asynchronously (e.g., video-otoscopy, cochlear implant mapping, multiview videofluoroscopy, etc.) would have some impact on the outcomes. These findings, as presented under the five themes, raise important implications for teletraining and telepractice globally and across health professions, but particularly in LMICs where access remains a significant challenge for both training and service provision. As evidenced by the studies included in this review, few studies were conducted in LMICs. This indicates a need for research in this area that will take careful consideration of all contextual challenges and formulate solutions that are contextually relevant and responsive.

FUNDING INFORMATION
The authors thank the National Institute for the Humanities and Social Sciences (NIHSS) and the Consortium for Advanced Research Training in Africa (CARTA) for providing financial assistance for the publication of this manuscript.

DISCLAIMER
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. The study showed the value of a blended learning approach, using elearning to teach theoretical aspects and experiential learning for students to develop practical skills. Given the opportunity, students may use knowledge and skills relating to eHealth in their future practices. The emphasis on education and training of eHealth may be an important step to address the slow uptake of eHealth in the workplace. Future studies must formally assess the effectiveness of eHealth education and training. This study provided evidence for the success of teaching clinical exercise online. However, workload may be perceived as heavy for students who choose to continue to work full time and there may be a need to support some online learning in practical subjects with in-person practical teaching sessions. The evidencebased recommendations provided as supplemental material to this paper may help online clinical educators and students maximize the success of their teaching and learning experiences, respectively.

Giudice et al. (2015)
Online versus in-person screening, brief intervention, and referral to treatment training in pediatrics residents.
Forty pediatric residents were randomized to receive either online or in-person training. Skills were assessed by pre-and post-training. Thirty-two residents also completed pre-and post-surveys of their substance use knowledge, attitude, and behaviours.
Pediatric residents at the University of Maryland Medical Center received 'screening, brief intervention, and/or referral to treatment' training as part of a Substance Abuse and Mental Health Services Administration-funded program.
Both groups demonstrated skill improvement from pre-to post assessment. Both increased their knowledge, self-reported behaviours, confidence, and readiness with no significant between group differences. Followup univariate analyses indicated that while both groups increased their SBIRT adherent skills, the online training group displayed more ''undesirable'' behaviours post training. Further investigation is needed to design and validate service-delivery protocols, particularly in the areas of speech perception testing and paediatric service delivery. There are limitations in technology and optimal listening environments (i.e., sound booths) in rural locations. Grewal et al. (2020) Tele-health and palliative care for cancer patients: Implications for the COVID-19 pandemic.
Limited input on methodology.
Service (single case study) Tele-palliative care offers great promise in addressing palliative and supportive care needs of patients with advanced cancer during the on-going pandemic. Continuous tele-monitoring can be used to remotely monitor crucial patientreported outcomes such as pain and respiratory distress.

Guiberson et al. (2015)
Accuracy of telehealthadministered measures to screen language in Spanish-speaking preschoolers.
Spain. Eighty-two children between 37 and 69 months of age and their families participated in this study.

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This research provides preliminary evidence of the effectiveness of a hybrid telehealth model in screening the language development of Spanish-speaking children. A processing efficiency measure, NWR, combined with a parent survey or language sample Physical in-person learning was perceived to be a more effective communication modality for clinical case-based discussions between a learner and an expert. However, remote, internet-based discussions enabled a more relaxed discussion environment. Good eye contact was observed in the three modalities, but less so in-person. Moffatt & Eley (2011) Barriers to the up-take of telemedicine in Australia -a view from providers 10 established expert providers of telemedicine services, combining Australian and international experience. Their roles/occupations included: moderators, academics, medical specialists, internet technology specialists, educators and program developers.
Provided an update on barriers to the uptake of telemedicine, in Australia, by the providers of telemedicine services.
These results raise issues in the domains of policy, funding priorities, and education and training. This indicates an interrelated set of challenges that would require a targeted multifaceted approach to address. The results suggest that not using telemedicine is, in the current climate, a rational response -it is quicker, easier and more cost-effective not to use telemedicine. A total of 1,210 participants agreed to complete the online survey questionnaire.
Explored whether the pandemic of COVID-19, which requires universities to rapidly offer online learning, will affect attitudes about online education for undergraduate health sciences students. Also, it investigated the barriers for using online tools.
Although the pandemic of COVID-19 appeared as uncommon catalyst for promoting eLearning, further research is needed to assess whether learners are ready and willing to make greater use of online education to obtain high quality teaching and learning opportunities; this could alter educators' and students' attitudes and impression, and subsequently the general themes of online education. Clinical knowledge of AHI is key to improving diagnosis. Schlenz et al. (2020) Students' and lecturers' perspective on the implementation of online learning in dental education due to SARS-CoV-2 (COVID-19): a cross-sectional study.
A total of 242 (166 female, 69 male) students completed the questionnaire.
Evaluated the students' and lecturer's perspective toward the new online learning courses through two online questionnaires (one for students and one for lecturers) in the challenging time of the SARS-CoV-2 pandemic.
Within the limitation of this study, students and lecturers showed a predominantly positive perspective on the implementation of online learning, providing the chance to use online learning even beyond COVID-19 in the future curriculum. Steventon et al. (2016) Effect of telehealth on hospital utilisation and mortality in routine clinical practice: A matched control cohort study in an early adopter site.
716 telehealth patients were recruited from the community, general practice and specialist acute care, between June 2010 and March 2013. Patients had chronic obstructive pulmonary disease, congestive heart failure or diabetes, and a history of associated inpatient admission.
Observational study of a mainstream telehealth service, using personlevel administrative data.
If telehealth is pursued, it may be desirable to create information systems to enable these services to respond to learning and to seek to improve their effectiveness over time. The methods used in this study, including linkage to administrative data, selection of matched control groups and sensitivity analysis, could be adapted to enable effectiveness to be tracked in close to real time. Tariq et al. (2018) Mobile detection of autism through machine learning on home video: A development and prospective validation study.
A mobile web portal for video raters to assess 30 behavioural features (e.g., eye contact, social smile) that are used by eight independent machine learning models to for identifying ASD. Each of these had >94% accuracy in cross-validation testing and subsequent independent validation from previous work.
Analysed item-level records from 2 standard diagnostic instruments to construct machine learning classifiers optimized for sparsity, interpretability, and accuracy. The present study prospectively tested whether the features from these optimized models can be extracted by blinded These results support the hypothesis that feature tagging of home videos for machine learning classification of autism can yield accurate outcomes in short time frames, using mobile devices. Further work will be needed to confirm that this approach can accelerate autism diagnosis at scale. non-expert raters from 3minute home videos of children with and without ASD to arrive at a rapid and accurate machine learning autism classification. Thomas et al. (2021) Synchronous telemedicine in allergy: Lessons learned and transformation of care during the COVID-19 pandemic.
A total of 537 synchronous telephone encounters were conducted.
Described the outcomes of the use of synchronous telemedicine for outpatient consultations in a tertiary adult allergy center.
Telemedicine can transform the current models of allergy care. Screening criteria for selecting suitable new patients are required. A telemedicine-based drug allergy service model can be more timeand cost-effective and improve patient access to specialist care. Walsh et al. (2011) Online teaching tool simplifies faculty use of multimedia and improves student interest and knowledge in science.
Sixty-three students registered to use the Online Multimedia Teaching Tool (OMTT).

Employed Adobe
ColdFusion-and Adobe Flash-based system for simplifying the construction, use, and delivery of electronic educational materials in science. The OMTT in Neuroscience was constructed from a ColdFusion based online interface, which reduced the need for programming skills and the time for curriculum development. The OMTT in Neuroscience was used by faculty to enhance their lectures in existing curricula.
The OMTT was rapidly adapted by multiple professors, and its use by undergraduate students was consistent with the interpretation that the OMTT improved performance on exams and increased interest in the field of neuroscience