Telehealth for Dysphagia: Is It Safe and Evidence-Based?
This is a transcript from our podcast episode published May 30th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.
A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.
Article / Transcript
[00:01:38] Kate Grandbois: We have such an interesting topic to talk about today. We are here to discuss dysphagia or dysphagia. The jury is still out for me on which pronunciation is accurate and tele-health, which just sounds so interesting.
And as our listeners know Amy and I work clinically [00:02:00] in a, the field of AAC. So we brought in our, I'm going to call you our dysphagia correspondent today. We asked our coworker and fellow nerd cast member Tracy Callahan to join us. Welcome Tracy.
[00:02:12] Tracey Callahan: Hi, thanks so much. I'm really excited to be here.
[00:02:15] Kate Grandbois: So we're excited to have you so that you can elevate this conversation and I know it's going to be really, really great.
We're also very excited to welcome Dr. Georgia Malandraki welcome, Georgia.
[00:02:26] Georgia Malandraki: Hi, everyone. Thank you so much.
[00:02:30] Amy Wonkka: Thank you so much for coming. You are here to discuss swallowing and tele-health before we get started, can you tell us just a little bit about yourself?
[00:02:37] Georgia Malandraki: Well, I'm a speech language pathologist. Just like you guys as well.
And, um, I'm a board certified specialist in swallowing disorders, but I'm also an associate professor in speech language and hearing sciences at Purdue university, where, um, I have developed a, the Purdue I eat lab. It is a lab that deals with, uh, the study of swallowing physiology and neurophysiology [00:03:00] across the lifespan and a secondary focus, which has become a rather primary focus in the last few years.
And definitely since the pandemic started has been the area of telehealth as well. So I'm very excited to be here today and to be, uh, discussing this topic with all of you.
[00:03:16] Kate Grandbois: I have so many questions. I know, I know we all do, but before we get into the good stuff, um, the powers that be require that I read aloud our learning objectives, as well as our financial and nonfinancial disclosures.
So if you're listening, I'm sorry that this is this, this is a required piece. It makes me read it so stick with us and we will, we will get to the good stuff in a minute. Learning objective number one, describe basic regulatory guidelines for the safe use of tele management of dysphasia. Learning objective number two, identify basic practical and clinical guidelines for the safe use of tele-management of dysphasia. Learning objective number three, summarize the research evidence available for the use of telehealth for dysphasia management and learning objective number four, describe new developments in wearable technologies for the [00:04:00] tele-management of dysphagia.
Disclosures Georgia's financial disclosures. Georgia is an employee of Purdue university and receives a salary and grants to support her work. Georgia also receives grants from the National Institute of health related to work in tele-health. Georgia is the co-founder of a Purdue initiated startup Georgia's nonfinancial disclosures.
Georgia is a member of, and the president elect of the dysphagia research society. She is also the Indiana speech and hearing association co-chair of the tele-health task force. Kate that's me, I'm the owner and founder of Grandbois therapy and consulting LLC, and co-founder of SLP nerd cast my nonfinancial disclosures.
I'm a member of ASHA, sig 12 and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis specialist.
[00:04:53] Amy Wonkka: Amy that's me, financial disclosures. I'm an employee of a public school system and co-founder of SLP nerd cast. And my non-financial [00:05:00] disclosures are that I'm a member of ASHA SIG 12. And I also serve on the AAC advisory group for Massachusetts advocates for children.
[00:05:06] Tracey Callahan: Hi, I'm Tracy. I am an employee of SLP nerd cast.
I own a private practice and I'm the owner of an online learning platform called guess monster games. My non-financial disclosures. I'm a member of ASHA and the corresponding special interest group, SIG 13 for dysphasia. I'm also a certified lactation counselor through the academy of lactation policy and practice.
[00:05:29] Amy Wonkka: All right, we've made it thanks for sticking with us listeners
[00:05:35] Kate Grandbois: It’s so long, we try to make it shorter every time, but we just felt weird. But here we are.
[00:05:40] Amy Wonkka: Oh, the other end, Georgia, could you start us off by telling us a little bit about that first learning objective? What, what are the rules? How can people be safe around tele-management of dysphasia?
[00:05:53] Georgia Malandraki: Yeah. Then this, this is a good question. It's a good first question as well. Cause a lot of, you know, a lot of times clinicians [00:06:00] tend to want to know about how can I do it clinically without necessarily looking at kind of the prerequisites before you look at clinical effectiveness or clinical at the patients.
And I consider some of the regulatory guidance a little bit as a prerequisite. So before you start thinking about clinical adaptations, I think it is important to think about laws and regulations that surround, for example, patient privacy and confidentiality, which is one of the biggest risks whenever you use the internet.
So whenever you use telehealth, that's one of the added risks that we have to address. And when we talk about dysphasia management specifically, a lot of clinicians also have safety concerns about their patients. So by abiding by regulatory laws and guidelines, you're actually also protecting yourself or mitigating some of the safety concerns and risks as well.
So things like, as I said, making sure that you abide by, uh, privacy and confidentiality laws for hospitals and clinical settings, the HIPAA [00:07:00] law, the FERPA law, when we're talking about schools, um, but also in addition to kind of this federal law, some states or even facilities may have their own regulations or status that you need to be aware of.
Uh, so that's another thing that you need to explore. So depending on the state you work in or the, uh, the facility you work in, it is important to investigate, um, talk to your risk management team, maybe or legal counsel. If, if you cannot find the information by yourself, talk to your state association or licensure board about what are some of the guidelines that may be state specific or facility specific for you, and then making sure that we abide by them.
I know that sounds very vague, but in reality, there are two ways to abide by those types of guidelines. One is by taking technical defenses, meaning making sure that you are using a secure platform, making sure you're using a secure storage space, a secure network, and, you know, uh, and these [00:08:00] are the things that hopefully an it person or it teams can help with.
Um, and then the second pathway to secure that you are biding by these regulations is to ensure that you have a consenting process in place. So both ASHA and the American telemedicine association, as well as state associations, highly recommend that you have a consenting process in place. I personally prefer a written consenting process, but even in some facilities in the states, even a retail, even a verbal I'm sorry, consenting process is fine.
So irrespective of what you will be using, I think it is important that you let the patients know about the risks, the benefits, your qualifications to use this, to this new service delivery model for many people, right? And also what the, what steps you have taken to mitigate any of these risks. And once the patient hears those, if they accept to continue, that's going to be up to them.
So I think those, those are the primary very, very now in a very [00:09:00] summarized overview way. Right. Um, is there some of the basic, uh, regulatory things that we need to think about at first? So privacy and confidentiality laws, the consenting process, technical defenses. Licensure requirements as well. That's another third thing that we need to think about, depending on the state, we work in a lot of licensure laws have been relaxed during the pandemic, but that doesn't mean that all states allow interstate, you know, uh, practices.
So you, you also, that's something that you also have to check with your state licensure board, and ASHA has some really great resources. I'm happy to provide some of these links. If you guys don't have them already, uh, for your audience. Uh, but th they have some really great, um, and, and, and constantly updated resources that they give for each state in terms of licensure.
And then of course, the other regulatory thing you have to consider is reimbursement. Which is a [00:10:00] is not negligible, as you all know, I'm sure. Right. Um, that has probably been the biggest hurdle. And again, I, uh, uh, I don't want to sound like an ASHA fanatic, but I do want to say that because of ASHA's efforts this past year and some of the state associations efforts as well, we finally were able to overcome at least temporarily some reimbursement hurdles as well.
So things are a little better. We're still fighting, uh, to, to make things better for the future as well. So I would say those, those three big things are, you know, privacy, confidentiality, uh, licensure and, uh, reimbursement. So those are kind of the regular regulatory things that you need to keep in mind and investigate.
Before you jump into the actual service delivery and usage.
[00:10:49] Tracey Callahan: And I think one thing that's really exciting is that we're able to continue to provide services to patients that really need it because just because there's a [00:11:00] pandemic doesn't mean that people don't need dysphasia therapy. So I think that it's been a really useful tool for those of us maybe who didn't use it before, but now I find that I really like it.
It's a really, really great tool.
[00:11:13] Georgia Malandraki: That's, that's great to hear. I've heard mixed things from clinicians. You know, some people like you really love it and want to continue using it. I would say probably at least half of the clinicians I talk to are belong in this category, but there are still a few that either, either very negative or they don't really know I'm sure. You know, so I think it is, it is, um, I, this is a challenge for us to persuade more people towards the positive or the positive things that can happen with the use of telehealth. And you're right. A lot of people can be very much helped irrespective of where they live or their ability to move and their ability to come to you.
[00:11:52] Tracey Callahan: Exactly. A lot of the patients that I see either live in a more rural area and the transportation is very difficult for them to [00:12:00] coordinate or physically the commute itself into a clinic is so taxing that by the time they get there, that they can't really do their best work. So I think it's a great tool and I'm excited, um, to continue.
[00:12:16] Kate Grandbois: So I have an obvious question. So when you're talking about telehealth as an overarching modality or a service delivery model, and there's obviously, you know, the person on the other side of the zoom screen can present with any myriad of, you know, this, you know, articulation, um, thinking of like the classic speech therapy, um, scenarios where your client or patient is engaged and looking at the camera, and you're able to create some sort of therapeutic environment, two dimensionally.
So, and, and again, I don't, this, this is not my area, but when I think of dysphagia. I think of how physically hands-on it is. And I think of [00:13:00] the risk of aspirating and how I'm not there to give the Heimlich, or I don't know, there just seems like this extra, super scary component. So you already have the service delivery model of tele-health, which is really different and challenging in a lot of ways, but then you add dysphasia onto that and I'm all, I'm very intimidated by this, even as an idea, and it's not something I do clinically, what can you tell us about that?
[00:13:22] Georgia Malandraki: Yeah. Well, I think thank you for asking that question. That's probably the most common question I get. Uh, so I will, I will answer it to the safety part first, because I feel like that's kind of the core of your question. Um, and then let me know if I left anything out and I'll try to address the first part as well.
Um, so what I want to say about safety, I understand, uh, I partly understand there's concerns. Um, uh, but I do understand, especially when they come from somebody who, who hasn't been doing this on a regular basis. So, uh, I think for those of us who have been treating patients in a regular basis in in-person settings, I'm talking [00:14:00] about now, you know, we all know that during any session, okay.
In even if it is delivered in a person versus telehealth, you know, whatever the service delivery model is at any in any session that involves oral trials of foods and liquids, there's always a chance that a patient with dysphasia may aspirate or in rare instances may even choke, but there is no evidence to suggest that that risk is in any form higher during a session with a dysphagia clinician, an expert versus during their everyday life, when they eat and drink, there's no research that shows us that.
And in addition to that, there is no research that shows us that during a dysphasia tele session the risk is higher than during a dysphasia in person session. So, um, I think this fear is a little bit exaggerated. So if you ask a dysphagia clinician, how many times did you have to do the Hamlet in an in-person session?
I [00:15:00] guarantee you it's probably unless, unless they're working with a very specific, very, you know, advanced, severe populate type of population, it wasn't very frequent. Right. Or it was extremely rare. The situation was, what about, I don't know, Tracy, if you have an answer? Once. Okay. So I would argue that just like an in-person sessions in telehealth sessions, we are the professionals who can actually mitigate those risks.
So for example, we are the ones who can decide, is it safe for this person to have oral trials. How can we make things safer? Can we have them perform oral care right before we start the world trials? Can we choose what we are going to give them the amounts and the volumes? This is something it's up to us to decide.
And then in addition to those things, having a facilitator present is a very important thing. When you are doing oral trials, especially with patients that you believe are at risk for aspiration. So th [00:16:00] so there are some safety things that you can do having a safety plan in place, which is actually usually a safety plan, uh, should be in place for all types of tele sessions, not just for dysphasia tele sessions.
And, uh, it's a, it's a plan that basically just says, what will, what are we going to do in the case of an emergency? So if you're not there to perform the Heimlich. So what will happen? So you have to have a safety plan in place that both the patient and their caregiver or their aide, or whoever is there with them will have agreed to in the beginning of the session is this is typically part of the consenting process.
So that has to be very clearly delineated. It's very similar to you and I being certified in CPR. That's a safety plan of the hospital or the clinic we work in, right. To be certified so that we can address an emergency situation when you're not there, you have to have another safety plan in place. So that is important to have.
But at the same time, I want to make sure that people understand that I don't want people to be so fearful of aspiration. First of all, [00:17:00] aspiration will happen. It happens with all of us and it is what it is. Patients with dysphagia are at high risk for aspiration. Choking, of course, is, is, is something to try and prevent of course, as much as possible.
And that's why I'm saying we are the collisions to decide what will happen in the session, how it will happen when. How to mitigate those risks as much as possible. Does that make sense? I think Tracy, you had a question.
[00:17:24] Tracey Callahan: Yeah. And, and when thinking about what we do for our dysphagia therapy that we would do in person, it's very similar.
So if I have a patient who is at a high risk for aspiration, I'm going to do oral care first, not just because it's on tele-health, you know, and I found as I was doing more tele-health that there were a lot more similarities than I initially thought, um, just this, we would, the same, we would pick oral trials, what order we would do them and the amounts that we would pick [00:18:00] the foods that we would pick, all of those things we would do in telehealth.
We would also do if we were doing in-person therapy as well.
[00:18:08] Georgia Malandraki: Yes, exactly. And, uh, yeah, and I think that kind of answers partly the, the first part of Kate's question about, you know, I'm not there to, you know, to touch the patient. I don't have, you know, that fear that, you know, you're not next to the patient or, you know, that's something that a lot of people are concerned about as well.
But the reality is, as Tracy just mentioned that a lot of the procedures we do are actually very hands off. So for parts of what we do, we may need to touch the patient. You know, when you do tracheostomy care, um, TP, things like that, you need to touch the patient or you need, if you're going to do telehealth, you need to have somebody who is knowledgeable the other end and you are really counseling them on how to do specific things.
Right? So those types of procedures definitely required facilitators that have extensive training. If not clinicians, actually not [00:19:00] just facilitators, right? But for most procedures of the clinical assessment or tele treatment, we don't need to touch the patient. You know, it used to be believed that you need to do laryngeal palpation.
Well, there was work that came out of the university of Wisconsin a few years ago that said that laryngeal palpation is 50% accurate. You know what that means? That means that the fact that if I use laryngeal patients identify a swallow. It's by chance accurate. Sometimes I will identify it as sometimes not.
And actually I would argue that, um, uh, with telehealth, because you know, there are things you can do, like putting a tape on the thyroid notch, moving the camera on an angle that you can see really well, moving the camera, really close to the head and neck, uh, in a diagonal way. I can actually visualize the swallow.
Sometimes I feel better than I could in person sometimes not with all patients. Of course, there's, you know, there, there is variation, but, um, but definitely, uh, you know, I had stopped using laryngeal palpation in the last few years anyway, so I [00:20:00] don't use it now. I don't feel that I'm missing anything.
There are things you can definitely, it's better to do them in person, or you can get more information in person than you could get, uh, via telehealth. So there's definitely some things that you can do as well. But I think the majority of, uh, um, the items that we examine in a clinical assessment. And the majority, not all, but the majority of things that we do in treatment can actually be done are very feasible.
And we are finding through our research that are also reliable.
[00:20:31] Kate Grandbois: That was going to be my next question about the research. So, I mean, I feel like, you know, our familiarity with tele-health has increased dramatically over the last year because we were so, you know, we were thrown into it. I have to assume that even just given advances in technology, the research on dysphagia and tele-health is somewhat recent.
Well, so what can you tell us about the, the evidence that's out there?
[00:20:58] Georgia Malandraki: Yeah, actually the reality [00:21:00] is that a lot of research that we did have a lot of research evidence, even before COVID-19 on the use of telehealth for dysphasia. A lot of that research was primarily, uh, focused on, uh, the reliability and validity of doing clinical tele assessments and how comparable they are with in-person clinical assessments and the findings were pretty good, very rather positive. And a lot of that research came out of Australia, which is a massive county country, very big country, and a lot of rural areas. So they, and they don't have the reimbursement that in order the licensure restrictions that we have. So they have been using tele-health for quite a while.
Um, so most of it was international research. We, we had also offered some research locally here in the U S um, and some across international borders, uh, that showed that also that both clinical assessments and videofluoroscopy assessments are also feasible and reliable via telehealth when compared to in-person assessments.[00:22:00]
Yes.
Kate Grandbois: That’s so surprising
Georgia Malandraki: Oh, yeah. So there are, there are research papers out there. Um, I have at least three or four publications on, on that topic. Uh, and telefluoroscopy publications, we have at least two or three on this topic. The issue has been, I think the, the reason why this research has never really been translated into clinical practice in the us and in most countries across the world, I believe has been.
I mean, there are many reasons, but I think the main reasons relate to, you know, the very strict regulations that we've had in this country. The other reason that I think is, is something for us, researchers to think about more. I think we now have thought about it a lot during COVID and have started acting on it relates to the fact that most of the research is done under very well controlled research conditions.
So it's not as easily clinically translatable, you know, like some of the studies that we were doing, we were using specialized cameras and specialized, very expensive equipment and pan and [00:23:00] tilt and zoom cameras and echo canceling microphones, and, uh, uh, you know, special headphones and, uh, echo canceling headphones.
Um, and you know, in microphones, special microphones and, you know, a lot of specialized types of equipment. Uh, we had very expensive infrastructure. We spend a lot of time doing trainings of facilitators that all the trainings were in person. So a lot of things that clinicians do not have available in their clinics.
So it's very difficult. Even if the regulations were out there, it would have been a very difficult, um, direct translation of the research. So that's, that's a thing, another hurdle that we have to overcome. And then I think the other, the third piece, which I now I'm understanding how important it is after having talked to probably hundreds of clinicians in the past year, I would say on this topic is, is that fear that you explained earlier that fear of aspiration of choking, of not being close to the patient, which I'm hoping we've, we've persuaded the audience that [00:24:00] it's, it's not, uh, um, I don't want to say it's not a logical fear.
I understand it, but it's, it's, it's a little bit of an exaggerated fear, but I think with the, with training and knowledge, it's a fear that can be overcome, uh, and with adequate preparation. But what I think those, you know, those. Too, there were those other two problems. And that's why that research was not clinically translated yet.
Now, uh, what I want to add here is that during the pandemic, I think we all realized, I mean, researchers that have done this work before as well, we all realize that we need to try and build the evidence under today's conditions and actually today's conditions that pandemic conditions are much more naturalistic.
Meaning, you know, the first few months of the pandemic, we were confined in our homes, the clinicians, the patients were confined in their homes, right. Uh, we wanted to keep. Providing services. So the only way to do it was to do it with whatever technology was available, whatever internet connectivity was available, providing [00:25:00] all the training online, because that's all we had.
Right. And see how it works. And we have some data that, uh, we, we got one, one of our papers that was published a few months ago was a collaborative study with Dr. Michelle Tosha from Columbia university in New York city. But one of her PhD students led and, uh, showed in a small scale of course, because it was a proof of concept study that even under very variable conditions, clinical tele assessments were still feasible and were still reliable even during today's conditions.
So that that's, that's type of that type of research we need more of, and we are continuing it, and I'm hoping that other teams are following as well. Uh, because we need more, uh, evidence under naturalistic conditions so that people can translate it clinically in a more rapid way.
Kate Grandbois: This is fascinating.
[00:25:52] Amy Wonkka: And we've talked a lot on here.
We've had a lot of researchers on across the field and kind of talking about that need. So it's [00:26:00] really exciting to hear that that's something that's already happening with dysphasia. And I think that also that type of real world naturalistic research is going to help make maybe some of those hesitant clinicians feel a little bit better too, because it's not just, you know, with these optimal conditions, it's, it's a bit more akin to like what you're actually dealing with as a clinician who's just treating in, in natural, um, contexts.
I wonder if, if another, this is a nice segue into talking about wearable technologies for tele management. I, I didn't know that this was a thing prior to working on these learning objectives. I'm super curious about this and, and maybe the number one, what are they, but number two, how might that help support a clinician who is providing teleservices in this domain.
[00:26:51] Georgia Malandraki: Yeah. No, thank you for the question. Uh, so I think the, so first of all, wearable technologies are, you know, any type of, you know, the clothes that you can wear, you [00:27:00] know, it could be your smart watch or, um, or some other specialized devices that are specifically designed for a medical reason that, um, can, um, monitor different types of data, biological data, biophysical data, and then transmit that data through a cloud server or by you sending the device back to the clinician to your clinician for further interpretation and further guidance. So we, we had seen even before the pandemic, the, uh, initial development of different apps, That people could use at their home setting, for example, to, um, to monitor adherence of different exercises so that that's not new, that was, that was happening even before the pandemic and those apps are available for people to, uh, to purchase most of them.
Uh, I believe some of them may be free some of the simplest ones. So that, that was one possibility for, uh, for, uh, for patients that was even available even before the pandemic. And now also there have been several [00:28:00] devices that have been developed in the past few years. For example, I don't know if you guys are familiar with the Iowa oral performance instrument, which is a device that you can measure tongue strengths and you can do, uh, tongue exercises, uh, with, um, and, uh, it is, it is a rather pricey device, uh, but it is a device that has a patient and
[00:28:22] Tracey Callahan: there's some like biofeedback information on that.
[00:28:25] Georgia Malandraki: Yes. And there are, what I was going to say is there are two devices. The one is for the clinician and one is for the patient that they can take home. Uh, um, it, it is still even the patient device is not, is not cheap. It's not economical. So that's one consideration that we have to think about, but those types of devices now connect to a cloud server so that the data that are collected at the home setting can be transmitted to the clinician via those cloud servers.
And there are similar devices out there as well. So this is, this is an area that we have been very interested in since I started working here at Purdue. Um, we have [00:29:00] been able to develop with some collaborators, um, a couple of different wearable technologies. The first one that is closer to commercialization is a wearable surface electromyography device.
It's kind of like a sticker device that goes on the neck and can monitor muscle activity when the patient is performing the exercises. Um, the device is connected through a wireless unit to an app or a software on your computer or your phone that, uh, gives you a biofeedback. And just like the IOP as we talked about earlier.
And. So the patient can actually see in real time how they're doing their exercises. And then the data are also, uh, are also transmitted to, uh, the clinician through a cloud server for further review and interpretation. Now, a lot of these devices, like the ones that I've been talking about, we have been developing are under development, so they're not available yet, but definitely I believe the future is bright.
There are other, uh, wearables out there with similar capabilities so that they give the [00:30:00] capability to collect some data at the home setting and transfer the data to the clinician for further, uh, review. And I think that, that is, the advancement and further development of these types of devices is not only good for telehealth.
I think it is important for in-person care as well. A lot of the treatments we have been doing with patients do not involve the use of biofeedback necessarily, or do not involve the use of accurate and reliable biofeedback. You know, it's different when you use a mirror or a tongue depressor, you know, that it doesn't really provide an accurate read of the behavior and very different when you actually use some objective data and we need to be moving more as a profession to collecting more objective data during treatment and during the evaluations, of course, uh, in general.
And I would say that that that's a very good advancement for both the in-person and the telemanagement of dyaphagia.
[00:30:58] Tracey Callahan: And then just [00:31:00] to, to comment on that, um, what's, what's great about having that data is that it can be really helpful for not only patients and for the clinicians, but also like caregivers.
It's good for everybody to see that there's progress being made, that you know, that it is increasing some of these you can chart and see progress with a graph, uh, which can be really rewarding. So sometimes when doing these different exercises, it can be a little bit boring, but having that type of feedback and taking that kind of data can be a really helpful tool to help encourage the patient or person to kind of press on with the exercises and activities.
[00:31:47] Georgia Malandraki: Yeah. Yeah, absolutely. It has actually been found that the use of exercises improves adherence, uh, for sure at the same time, if, as a field, we want to move forward to a more or less [00:32:00] symptomatic treatment approach and a more physiological treatment approach. We need to be using exercise physiology principles, and those principles are telling us that we need to be working towards targets.
If we don't have targets, you will only be able to improve the patient to a specific level and then that will be yet, you will get a plateau very quickly. So I think that's, that's another very important reason to, uh, continue working in this domain of developing more and more, uh, accurate and also affordable devices, because I think that's the biggest problem.
The biggest problem is because this is a very small market compared to, you know, markets of other things that, you know, um, make a lot of money for people. Unfortunately, these devices end up being very costly and right now, not many of them, if any, are reimbursable. So there's a, these are hurdles that we need to, we have been working on and we need to be working on more.
[00:32:56] Tracey Callahan: I know that Kate and Amy both really love data. [00:33:00] Data is probably one of their favorite things that are able to provide really specific and objective data, uh, I think are, are wonderful. But also when we think about when we're doing therapy to know the improvement is there, other than just, they were able to swallow X number of bites over three sessions, you know, it's good to have some measurable numbers.
[00:33:26] Georgia Malandraki: Absolutely. Yep.
[00:33:28] Kate Grandbois: Can you tell us a little bit about any specific adaptations that, so just thinking about a clinician who might be listening to this, who has experienced doing this kind of treatment in person and is interested, maybe they live in a rural area or they're interested in exploring tele-health.
What are some of the specific adaptations that a clinician, a practicing clinician might need to consider when setting up tele-health for maybe the first time or the fifth time or the 10th?
[00:33:57] Georgia Malandraki: Yeah. Yeah. So first of all, I would [00:34:00] say just, um, uh, just to make sure I repeat it enough that all these, the prerequisites that we talked about about the regulatory guidelines, the infrastructure, and all of those things, those need to come first and all those considerations.
And once those have been taken care of, I think, um, there are actually relatively simple, uh, but a little bit time consuming adaptations that people can do. Meaning I think the, the biggest thing that you need to understand and do is that you will need some time to prepare materials, you know, um, in tele health, unlike in in-person services.
Most of the times you need to make sure that the patient has the list of items you need them to have in front of them before the session starts, you know, in, in the clinic, you can grab something. If you forget something, usually you have pockets, right? Um, full of stuff or drawers full of stuff. So you can easily, uh, you know, do something else or have a plan B of what you want to try or how you want to do [00:35:00] things. With the telehealth you have to be pretty well-prepared. Yeah. For both plan a and plan B. So that's the biggest thing. So I would say you need to spend some time in the beginning. If we're talking just about clinical adaptations, for example, to maybe prepare some online materials or purchase some online materials. There's so many things nowadays available, create online forms, uh, and use secure platforms to deliver those forms.
Um, you know, case history forms on, you know, things like you may be using the eight, 10 as a or other quality of life instruments. You may be using the MOCA or other cognitive screens, whatever, you know, whatever you use, you will need to make sure that you're using the appropriate electronic form. If you are going to be transferring into an electronic or a remote environment only.
So that those types of things need a little bit of preparation. So that's, I think that's something that clinicians need to think a little bit about more. Also, you know, in terms of the items that you will need in the clinical assessment. [00:36:00] Uh, so what we have done is we have prepared like very cheap tele-health kits.
And, uh, we usually send a list of items to the patient and if they cannot collect all the items that we believe are necessary, then we will consider sending them that very small tele-health kit so that they can, uh, have the items we need them to have in front of them. In case they didn't have them at the home setting at the same time, you need to be a little flexible because they may have something similar to what you wanted to try, but not exactly what you wanted to try.
So you can decide how flexible you want to be. And again, this takes a little bit of preparation and communication beforehand. So, so there is some, um, initial time that has to be spent. The good thing I think. And those of you who have done the health, you know, as well, is that once you prepare uh, well, once you usually have material for quite a few more patients, right?
So of course you need to make adaptations and you need to change a few things and a few of your stimuli and things like that. But especially for dysphagia care, things are [00:37:00] relatively standard. Of course, the way you do things change, but typically the types of things you do are not that different. Um, so, and they're not exhausted, you know, there's not an exhaustive list that you can't really possibly, uh, uh, prepare materials for most of it.
So I think preparation is a big thing. And then when, when it, when it comes to the actual clinical application, the important thing is to be able to have the materials you need and to be able to see and hear well what you need to see and here. So you have to check to make sure that the internet connectivity is adequate.
And this is something that we extensively talk about in some of the webinars I gave for ASHA and also some of the, um, the papers that the guidance papers that we published this past year. So for those of you who are interested in learning more about it and testing, then, you know, as I said that the internet connectivity and the technologies, the patient has to make sure that you have the, uh, adequate audio and video [00:38:00] for what you need to see and hear when it comes to the actual, uh, uh, you know, down to the day where you actually have to do the assessment, simple things, for example, like moving, I think I mentioned earlier, like moving, moving the head diagonally and moving the camera close to the patient so that you can see the head and neck well. Putting a tape on the thyroid notch helps with visualization of the swallows. It's not perfect, but it can be helpful, making sure that you use clear cups.
And I like to use measuring cups so that I can see how much volume is being consumed as well of the different materials, you know, simple things like that can actually enhance the process really well. The other thing I really like using, especially for swallows or any type of oral trials that the patient is doing, I like having a second camera and buy a second camera.
I don't mean going out and purchasing a it's an expensive, uh, know second external camera, but actually what we have been using during the pandemic, which wouldn't believe it would [00:39:00] work, but it worked really well is just using a phone. So we would send the zoom healthcare link to other the facilitator, the caregiver, and they would also connect to the session as an extra participant through their phone.
They will use the camera with our direction as, uh, a close up camera. So I could see the patient from their regular camera in the front view. And then I would have the caregivers or facilitators phone providing me the lateral views, the diagonal views, the views inside the mouth, you know, things like that.
So, so a simple solution like that, that. Really came out of necessity. We didn't know what else they use during the pandemic to make things more visible for us and better to visualize things better. And we tried it and it actually works much better than some of the pan tilt zoom cameras I was using a few years ago when I was doing tele fluoroscopies.
So it's, it's, you know, technology has advanced so much in the last few years and it's [00:40:00] really, it's becoming more of our friend now in the area of tele-health. Um, so you know, those, those simple things I would say, and I probably mentioned too many, but, um, just to get an idea,
[00:40:10] Kate Grandbois: no more information is always better.
There's no such thing as too many, too many things. I'm wondering about the requirement of a facilitator and you've mentioned caregivers a few times. Is this an adaptation or something that's different that you feel is a requirement first? Or does the evidence say that it's a requirement for successful dysphagia intervention over telehealth?
[00:40:32] Georgia Malandraki: We don't have definitive evidence that says that it is absolutely necessary or not. We do have evidence that says that, uh, facilitators can get drained and can be very helpful. Uh, what I would tell you based on my experiences is that for clinical assessments, I consider a facilitator,I make it a requirement that a facilitator is present because there are many parts in the clinical assessment.
Uh, like for example, I [00:41:00] want to try and test, uh, sensory responses. I want to try as part of the cranial nerve examination, or I want to try and test, uh, strength responses to the best of our ability. Of course. So the use of a facilitator for these types of things is very important in addition to, of course, as I said earlier, it, it, you know, it can be part of the safety plan.
Um, so it, it can give me peace of mind. So for clinical tele assessments, I do find them necessary. And I, I personally require them in our clinic. For tele treatment sessions. Uh, there could be situations that they're not absolutely necessary, but I think that will depend highly on the age of the patient, their cognitive status, their general health status.
And very importantly on what has been decided as the safety plan and agreed upon as the safety plan, because if your safety plan says that there will be a facilitator there, and that is what the patient has agreed to, then you need to have a facilitator present, but that's [00:42:00] not necessarily required if that's not what the safety plan says.
So I throw it a lot, depends on all these other factors, plus the safety plan as well. And one thing I want to mention, it's not related to facilitators, but because I feel like I'm talking about tele clinical assessment until the treatments, and I'm not talking about instrumental assessments at all. I don't want people to think that I believe that we don't need these instrumental assessments by any means.
They're a very big part of what we do. Very, very important. Right now, there are ways to use telehealth for instrumental assessments, but those ways are either very expensive. And, you know, for example, for televideofluoroscopy, you need to get buy in from radiology as well to buy specialized equipment to do that.
And in addition to that, they're are not assessments that you could do from the home setting. You know? So until we will develop that, x-ray,
[00:42:50] Amy Wonkka: I was trying to picture what that would look like.
[00:42:53] Georgia Malandraki: So we don't have that ability yet, but, you know, but if you wanted to do, for example, from a big cost to that, to a rural [00:43:00] hospital or something like that, that is possible.
If the technology is there, it is expensive technology. So that's one barrier. Uh, but that is a possibility. The other possibility for tele instrumental assessments is to do, to use asynchronous telehealth, which means, you know, somebody can conduct their assessment in real time. And if they want a second opinion or another more experienced clinician to take a look and give them a further interpretation to store and forward it, or basically save it and transfer it in a, in a safe way to another clinician for later review.
So that that's a possibility as well. There are billing issues there and complexities in that case, but there are ways that ways to do those types of things. So just wanted to make sure that I touched base on that because I realized I was talking only about two things and I didn't want people to think, oh, she doesn't do instrumentals that's that's not at all, uh, to,
[00:43:55] Amy Wonkka: no, we appreciate that.
I think, I think one question we had kind of to back [00:44:00] up even further from what we've been talking about, how do you figure out who is a can, Iis everybody a candidate as a patient for teleservices? If not kind of, how do you figure that out? Or what are some questions that clinicians should be asking themselves? If they're curious?
[00:44:16] Georgia Malandraki: Yeah, no, I think that's also a very good question and it is also a very common question. And one thing that, uh, Uh, I tell clinicians is that, uh, because a lot of people say, you know, what types of patients are candidates? And there's not really a good response for that question, because it's not about the type of, or the diagnosis of the patient.
It's really about, um, a process of thinking of who could actually do this and benefit from this. And we are developing an algorithm that will be published very soon in SIG 13 perspectives. So hopefully it will be available to many clinicians to see very soon. Uh, but in this algorithm we're using a four step approach.
So here, so this [00:45:00] is what I'm thinking. So usually when I have a patient and I'm thinking, are they a candidate for tele-health irrespective of their diagnosis? Okay. Or severity, I will first think about some very initial tele specific factors. So for example, do they have adequate enough hearing and vision and alertness to be able to attend.
30 minutes, 45, an hour session, whatever, whatever I believe this patient needs, right. Are they able to be positioned in front of a camera for a specific amount of time so that I can see and hear what I need and out? Are they capable to consent or do they have a proxy who can consent for them, you know, and go through the consenting process.
So those are kind of the more general tele specific criteria that are true across different settings, not just for dysphagia, right? If the answer to all of this is yes, then I move to the next step and I say, okay, now let me see, do I have the infrastructure available? Do I have, especially at the patients and [00:46:00] adequate connectivity and technology available, if not, could I get services that will give them the technology?
So for example, just like you guys have AAC lending libraries, we're starting to have tele-health lending libraries with iPads and things like that, that we give out to patients. If the answer is yes, then I moved to the third step of the process and questions, which is now I'm asking about the clinical factors.
Do I have all the materials I need to do what I need with the patient? Or can I give them the material? Can I provide that to them? If the answer is yes, then I go to my last question, which is, is a facilitator available, able, and willing to help and to act in the case of an emergency. And again, this is not absolutely necessary at all times, but it, for dysphasia tele-management, I very highly recommend it.
And if they, if a facilitator is not available, does that mean that the patient is not a candidate? Not necessarily, it will depend, as we said earlier on age [00:47:00] medical status, cognitive status. And what is the emergency plan situation is something else we could do if a facilitator's not there if an emergency were to occur.
So it is, it is, it is a multi-step process that, uh, that you have to think about. Instead of thinking about this patient versus this patient versus this diagnosis versus this age group, it's really more of a process. Does that make sense?
[00:47:25] Amy Wonkka: It makes a lot of sense. And I think, you know, you, you already made the point, but just to sort of restate it.
I think that so many of the things that you're talking about are applicable broadly when we think about telepractice in general, like these are, you know, the infrastructure questions that you should be asking yourself, you should have these things in place. You should have a way of assessing, you know, the hardware capabilities of your client.
Like just, just the very logistical pieces really do need to be ironed out before you even get to the clinical piece sort of at all. Um, sorry, go ahead.
[00:47:58] Georgia Malandraki: No, it was going to [00:48:00] say, and that relates to that preparation that I was talking about earlier. That's part of it, you know, you need to do possibly, you know, a five to 10 minute trial session.
You need to, you need to spend that extra time. I understand it's not always reimbursable, you know, it's it's time and energy and all of those things. So I think another important consideration, and I think I talked about it, especially in the latest ASHA, um, uh, webinar. Uh, I think it is important for people who are really serious about it and want to make sure that they can use telehealth beyond the pandemic.
They really need to think about how do I fit this in, into my work flow, because there will need to be some initial time and energy spent. But I think if you do that extra preparation in the beginning and incorporate the use of telehealth into your workflow already, then it will be much easier to sustain it long-term and beyond the pandemic, I believe that people that don't want to use it anymore are the people that didn't do [00:49:00] that. Didn't do the preparation. They jumped into it very quickly because they had to, and they realized it's a lot of extra steps. It's a lot of extra effort and they didn't want to be doing that every time because they didn't put the preparation time in and they didn’t incorporate it in their workflow in the beginning. So it's all, I think part of that preparation time.
[00:49:20] Amy Wonkka: Well, and I think too, you know, you've talked about your specific institution, but I think that, you know, that's something else to think about. It's just at the institutional level, if you're working somewhere, you know, can you recruit, because some of this stuff you could potentially allocate these jobs to other people and kind of divide the workload up a little bit.
That makes it feel a little bit more manageable. Like one person can come up with, you know, a bunch of sample, um, bandwidth, you know, even, even just really logistical stuff, like is your bandwidth this go on here and check it. Um, and so doing that at an institutional level, I think it's probably,
[00:49:54] Georgia Malandraki: yeah, we, we actually, for [00:50:00] the testing of the connection, we had the receptionist in the clinic do that.
You know, I mean, we, we trained them. We spend a little bit of time with them and said, this is what you need to do. This is what, you know, you connect, you go to this website, you check, you know, you ask the patient to do the same, you'll share your screen. You know, we, we shared some steps with them and they started doing it from then on, uh, we had, uh, some graduate assistants, do some other parts.
So depending on where you are, um, and what type of help you can have. Definitely, you can definitely, if you have help, that's great. And, uh, you can definitely allocate. Absolutely.
[00:50:33] Tracey Callahan: And one thing that, you know, some people were concerned about was the extra time for the patient, but I've actually found that the patients that I've seen really appreciated that we took the time ahead of time to make sure that their connectivity was there, that they knew where they should be positioned, uh, what equipment they should bring and that they were given time to ask questions about how the whole process would work.
[00:50:59] Georgia Malandraki: [00:51:00] Yes, absolutely. I find the same overall. Um, as I said earlier, there are always some people that it doesn't work for them, you know, that, um, uh, and especially, I don't know, but where, in what states you guys are located, but here in Indiana, we had a little bit of trouble with some of the older folks. Um, we, not all of them, but, you know, with some of them.
So that was that, that was actually a challenge that we had to address. So we had to create step by step instructions and, you know, and do more trial sessions with them and all of those things. Um, and then after that, it worked much better, but overall, uh, overall I feel like it's actually. In, in the context of all the time that is allocated to a session from the patient's perspective, it's a time saver because they don't have to drive to the clinic. They don't have, you know, um, some of our patients drive from far away. Um, so that's a big time saver and energy saver and money saver too. So I [00:52:00] think, I think they have appreciated some of those components as well.
[00:52:04] Kate Grandbois: I wonder if you could walk us through maybe a potential session, just for someone who is listening, who wants to, you know, we've got the lay of the land, the larger landscape, the safety precautions, some tips and tricks, but if you could go through a pretend session with us, maybe in sequence, I think that would be really interesting.
[00:52:26] Georgia Malandraki: Okay. I'll try it. So is it a tele evaluation or a tele treatment session?
[00:52:34] Kate Grandbois: Oh gosh. It doesn't matter. You pick dealer's choice.
[00:52:34] Georgia Malandraki: Okay. Well, the, the, the big difference is if it isn't an evaluation session and it is the first time or one of the first times I'm meeting the patient, I will have spend about 10 to 15 minutes before to, uh, to train both of the patient and the facilitator on the safety plan.
And it literally doesn't take more than 10 to 15 minutes for most situations. But I go through that because that's also part of the consenting process. Um, [00:53:00] and that that's, that's something that, you know, uh, with training of probably a graduate assistant or another assistant could possibly do in another clinic.
But in the beginning, I usually, uh, tried to do it myself and the patients feel better that way. Um, I'm also probably the fastest in doing so going through that plan, it's a two page document. We go through it and we just say, you know, this is, uh, I'm explaining the risks and the benefits, this, uh, this is a, I'm explaining that our qualifications to do this, I'm asking them if they're willing to do it after I explain everything.
So the part of the consenting process, and then I'm telling them that just like any other medical procedure, there are some safety things that we need to talk about. So I talk to them about, um, any safety concerns they may have about these risks. I answer any questions they have and once they agree, after that we're ready to start with a clinical session that can happen right away, or it could be, it could be another day that is being planned. If it is another day, the only thing [00:54:00] is before you start the session, you want to remind them, do you remember the emergency plan? What is it? What did we decide?
Who's going to call 9 1 1, you know, ask some of those safety questions, take two minutes. Literally. No more than that. I promise. And then after that, and that's something you actually, we asked in the beginning of every session about or treatment. Okay. And then after that is answered and we are set that everybody knows their roles in the case of an emergency, then we can start with actual session for the clinical evaluation. We start with an interview process, a case just like you would start in in-person in clinic. Right. Uh, usually they will have completed a form. So we use that form to go through the responses, make sure they're accurate, uh, ask any clarification questions.
And then we start with the cranial nerve assessment. Also, if they, if they have done any other questionnaires, we will also go through those questions as well. We will do, uh, the, the cranial nerve assessment. Uh, and that that's the [00:55:00] part where the facilitator will also be very helpful. Then we will do the oral trials.
Uh, and then at the end we will spend 10 to 15 minutes to kind of summarize what we saw. Uh, we usually, I usually record part of that session. I don't record all sessions. So you don't, you don't necessarily have to record session. Actually. It could be a breach of confidentiality if you record those sessions.
So that's another thing that you need to check by state reimbursement agency and all of that and facility. Uh, but I, I do record some of the evaluation sessions because sometimes I will go back and rewatch just to make sure that I captured all elements of the evaluation. Um, but we spend the last 10 to 15 minutes to basically summarize what happened, what we saw.
We usually tell them that we will tell them more things in the next session. Um, if it's just an evaluation session and ask if they have any more questions, how did they feel about this encounter? If there's anything we could change. Um, so some tele specific [00:56:00] questions and, and that's basically it, uh, I don't know if I forgot anything.
I probably forgot some of the cognitive screens and things like that, that we do. Uh, uh, but th those are usually part of the interview process in the beginning as well. And the treatment session is similar, but, you know, instead of the clinical evaluation steps, you follow you, uh, you go through the different instructions for the clinical, uh, for the, for the treatment.
Um, we do have a lot of materials that we have prepared that we screen-share with patients. So for example, for the cranial nerve assessment, we have almost step-by-step pictures of what we want them to do. Now. Of course we are modeling it for them as well, but just in case they can't understand, we have step by step instructions.
We also have step-by-step instructions for the facilitator. So that's part of the preparation that has been done. Um, so yeah, so that's what that would look like
[00:56:57] Tracey Callahan: One thing I think is really [00:57:00] unique, um, about, uh, doing the assessment through tele-health is you're able to visualize what the patient is actually likely to be sitting in, what their positioning is going to be.
Um, so in different clinics that I've worked in, we've had, you know, very expensive therapeutic chairs with bands and pillows and, and that's not realistic for most, if not all of our patients at home. So it's good to have that as part of the process. Uh, so we can make sure that the patient is realistically going to be positioned appropriately.
And if the positioning isn't working, it's really great to work with the caregiver in real time to troubleshoot that and figure out what we could do. Okay. Could we bring in a box or a stack of board games or books underneath the feet to make sure that the patient is well supported or can we get some pillows for lateral support?
And, um, and I think that's just really unique to [00:58:00] telehealth. I mean, also to home, home care, but thinking, um, difference between a clinic it's been really helpful and families and caregivers have really appreciated that aspect.
[00:58:13] Georgia Malandraki: Yeah. I think that's a great point, Tracy. Absolutely. The, the, you know, you are in the naturalistic environment and, uh, in addition to, uh, all those things that you mentioned that are very, very helpful, especially in pediatrics.
I know we haven't talked much about pediatrics, but hopefully a lot of the things we've covered also, uh, will be relevant to your pediatric, uh, clinical audience, but also the fact that, for example, especially in pediatrics. So the other thing that I have found very useful is that a lot of the materials have to be prepared by the caregiver at home before, so they are the materials that they have available. They would use in, in everyday life. They're not the materials that you just have in the clinic. So that's another way to generalize things much [00:59:00] faster.
[00:59:01] Tracey Callahan: I agree that also thinking about, um, different cultural foods that people might have at home, that we don't have.
One of the big complaints that I used to get was that people wouldn't eat chicken and, uh, the hospital would serve white meat chicken, and a lot of countries in the world do not believe that that is delicious. And so at home they're having the darker meat, chicken, or they're having part of the leg, or, or the thigh and, um, you know, that's really different, whereas, you know, I can't go down to the kitchen and say, no white meat, please. I would only like dark meat chicken for my trials today. It's really great to be able to have that available. And also if we're working on eating crackers with a patient, but they're not eating crackers at home, then you know, it's not really a useful goal to work on.
[00:59:53] Georgia Malandraki: Yeah, absolutely. And you know, when we ask them to prepare like a list of items, [01:00:00] a lot of times we will give them just examples of things that they have available. And, and it's, it's, I know that the bad thing is we can’t standardize across patients if they're each one is using their own thing. Right. But, um, but the clinical assessment is essentially, um, of course, ideally you want to have as much standardize information as possible, and you can supplement that with standardized tools, but, um, when it comes to oral trials, because food is such a personal experience and as a such a cultural experience, as you said, I think it, it actually, uh, is, uh, has been very helpful for, to see what the different patients can come up with and what they want to try and, uh, how they do.
So, yeah, absolutely.
[01:00:41] Kate Grandbois: In our last minute or two, do you have any words of wisdom, if you could, you know, in reaching through reaching through the headphones to a clinician who is maybe just starting this, this at clinical adventure, do you have any, any pieces, last pieces of advice?
[01:00:59] Georgia Malandraki: That's a, that's a pretty [01:01:00] heavy question.
No pressure, no pressure at all, right? Yeah, no, I mean, I would say that, um, uh, you know, as anything else that is new. Uh, and requires a new skill. It needs time to be learned, but it's definitely something you can learn. And it, it, it needs time and investment, just like anything other new skill that you would like to learn.
So, um, I would just recommend making sure to spend the time nowadays, there are many resources available, many webinars available. I believe there's going to be more and more trainings available in the upcoming months and years on this finally, because of COVID that was probably the silver lining graduate programs and incorporating this in their, you know, in their curriculum.
So I believe, um, you know, there will be more and more resources. So I think if somebody and there are resources out there, so I believe that if somebody is really interested, they just need to be patient and give themselves [01:02:00] time. Yeah. Uh, and the investment of time and energy and money will pay off if they're very serious about it at the same time.
Uh, you know, I just want to reiterate that we do have research evidence. We're starting to have more research evidence under more natural listing conditions in cause you know, I do hear a lot. There's no evidence. This is unsafe. This is this. This is that. If you don't have the knowledge, this is what you think. Your fear of something that is unknown.
So I want to reiterate that there is knowledge out there. There are guidance, there are guidelines and there is some research. So just do your homework and take the time. And, uh, and one day you, I think you will be very glad you did.
[01:02:46] Kate Grandbois: Those were wonderful last words. That was, that was great. This whole conversation has been so wonderful.
Thank you so much for joining us. This was, this was so awesome.
Amy Wonkka:Yes. Thank you. If anyone,
[01:02:59] Georgia Malandraki: thank you for [01:03:00] having me. I, you know, it's, it's great. You guys asked great questions and it was a great discussion. I appreciate having all of you here. Thank you. Believe me.
[01:03:07] Kate Grandbois:The pleasure is on this side of the microphone, for sure.
This was really great. If anybody is listening and would like to earn this, use this episode to earn ASHA CEUs, you can do so on our website, www.slpnerdcast.com. All of the resources that were mentioned will be linked in the show notes. So if you've listened and you want to learn a little bit more, dig a little bit deeper, read a little bit more literature, all of those resources are available for you in your podcast player or your phone or wherever you're listening.
And we're, we're so glad to have you today, Georgia and hope everyone learned something today. So thanks again.
[01:03:41] Georgia Malandraki: Very glad to be here.
[01:03:44] Kate Grandbois: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body.
To determine if this episode will count for professional development in your area [01:04:00] of study, please check in with your governing bodies or you can go to our website, www.SLPnerdcast.com. All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email at info@slpnerdcast.com.
Thank you so much for joining us and we hope to welcome you back here again soon.