While the increased interest in telepractice created by the COVID pandemic has been positive, there have also been recognized challenges associated with the forced adoption and rapid uptake of telepractice services [
9,
18,
81]. There are real concerns that some clinicians and organizations adopted telepractice without the training, infrastructure, and experience that would be expected in less-urgent times, and that this may have impacted the safety, effectiveness, and acceptance of some telepractice models [
9,
18,
81]. The lessons learnt during this rapid transition to telepractice require some pause, reflection, and reconsideration. Many of the “failures” experienced can be tracked back to inadequate time for service implementation, and a lack of skills, knowledge training to work effectively in a telepractice environment. For others, it was a lack of access to appropriate resources that created major barriers. Negative clinician perceptions about perceived issues with the “quality” of telepractice services also created initial clinician reluctance and doubt. All of this was not unexpected.
Then, clinical teams need to have adequate supports to help make this service change happen. Just like establishing any new service, the development of telepractice services must involve careful consideration of numerous factors [
16,
18,
82,
83]. It is important for clinicians to have a robust understanding of their clinical service, care requirements, consumer needs, and technology options when developing telepractice services [
83]. To help guide clinicians through the complex process of implementation, Martínez-Alcalá et al. [
82] outlined that the development of user-centered telepractice services requires four stages:
analysis, design, implementation, and evaluation, with each of these discussed further here in this section.
Design
Once the analysis stage has been completed, the
design phase focuses on the conceptualization of user requirements and the development and trial of the telepractice system. The design process is imperative, as poorly designed systems can negatively impact telepractice uptake, usability, and sustainability [
9,
81,
83]. In a recent systematic review, Almathami et al. [
85] identified system-design issues, including environmental obstruction, difficulties using the system, technological incompatibility, and even device size and weight, as being barriers to telepractice uptake. Clinicians should be able to identify what type/s of technology would be the most effective for their service and task needs, and how they will adapt tasks for the telepractice environment [
59]. It is recommended that clinicians engage in a testing phase where they pilot their developed system with end users to reflect and redesign the system prior to implementation [
59,
84].
Integral to this design phase is also consideration of existing policy and infrastructure [
85‐
87]. Technology infrastructure can impact internet access and internet speed in some areas, which can influence the availability and quality of telepractice services [
85]. Issues with security and privacy are also frequently cited as barriers to telepractice service delivery [
85,
87,
88]. While levels of data security are mandated in some countries (e.g., the USA, Australia), they are not in others [
89]. Data security is a serious issue, and providers and patients will continue to lack trust in telepractice services without adequate security and privacy protections. Finally, issues with payment and reimbursement also need to be addressed for telepractice models to be successful and sustainable [
85‐
87].
Implementation
The
implementation stage [
82] then involves use of the designed telepractice system in clinical care. In this phase, clinicians need to have a strong understanding of when and why to use telepractice, as well as the ability to assess patient suitability, practice readiness, and technology needs [
81]. Thomas et al. [
9] reported that the COVID-19 pandemic has reinforced that a large proportion of the health workforce have not been adequately trained in how to deliver care via telepractice. They emphasized the need for telepractice to be embedded in university and health training programs to ensure that graduates are “telepractice ready” and discussed the need for the development of discipline-specific guidelines, ongoing staff training, and for professional associations to consider telepractice accreditation [
9]. Part of this training is not only having the knowledge of how to deliver a specific task via telepractice, but also an awareness of the larger issues surrounding a clinical telepractice service. For example, Galpin et al. [
81] stressed the importance of recognizing patient safety issues when delivering telepractice services. Appropriate education and preparation of patients to ensure they are able to competently and confidently use telepractice is also crucial to implementation success [
81]. Furthermore, organizations and individuals must have a comprehensive understanding of their national, state, local, facility, and practice standards, as well as funding requirements, and ensure that they communicate effectively, act professionally, and maintain ethical behavior during telepractice service provision [
9,
81].
Evaluation
Martínez-Alcalá et al. [
82] described the final step of the process to be
evaluation. A comprehensive and ongoing method of evaluation is required to ensure that any new telepractice model is both effective and continues to meet both service and user needs. This evaluation process should be multifactorial and not only examine the effectiveness of telepractice, but also examine clinician and patient experience/satisfaction, patient outcomes (including quality of life), and economic outcomes [
9,
84,
90]. It should also try to capture the many traditional benefits of telepractice such as time and financial savings, improved service access, and increased convenience for consumers [
27,
30,
33,
54,
85,
91,
92] as well as consider new benefits identified since COVID-19, such as the ability to continue delivery of clinical care during stay-at-home orders [
6,
15,
93] and reducing the need for personal protective equipment in times of resource shortages. As there are many potential impacts from introducing telepractice, service evaluations need to be robust, and sensitive to the context in which the service was introduced, in order to fully capture the impact of new telepractice services.
Understanding clinician and client perceptions is another key component of any telepractice service evaluation, as studies have demonstrated that end user satisfaction can significantly influence the uptake and sustainability of telepractice [
94]. Variables evaluated in the literature have included comfort, perceived privacy, ease of use, technical functionality, user experience, and perceived usefulness of telepractice [
95,
96]. Standardized questionnaires, purpose-built questionnaires, and/or qualitative interviews have all be used to examine perceptions and satisfaction [
90,
95,
96].
In particular, understanding clinician attitudes about telepractice is crucial, as it has long been recognized as one of the main barriers impacting uptake of telepractice services [
86,
97‐
99]. A common misperception held by clinicians who have not experienced telepractice, is that telepractice is a “lower quality” service option, offering patients “less” than a traditional in-person service model. However, it has also been shown that once clinicians have had exposure and opportunity to use telepractice, these perceptions change [
99]. Indeed, studies of clinician perceptions delivering adult dysphagia telepractice models have revealed high satisfaction, with SLPs reporting that they are able to complete the assessment adequately, establish patient rapport, and use technology easily [
27,
33,
41,
47‐
49]. Such positive clinician feedback has also been found in pediatric telepractice models [
37,
54,
58]. Although Ward et al. [
47] and Ward et al. [
41] did report that in a small number of adult CSE sessions, the telepractice clinicians were not satisfied with the session, further analysis identified that these particular sessions involved patients who were unable to follow verbal instructions, experienced fatigue, distress, or agitation, and had significant hearing or vision impairments or excess body movements [
46]. All of these characteristics would create challenges during in-person consultations as well.
Examining client perceptions is also integral when evaluating the success of any telepractice service. Clinicians have long misperceived that certain clients would not be interested in, or accepting of, telepractice models of care, and/or that clients do not have the appropriate computer skills and technology to access these services (particularly for older adults) [
97,
98]. However, in direct contrast to these early assumptions, research into consumer perceptions of telepractice models used in both adult [
27,
33,
48,
100] and pediatric dysphagia care [
37,
54,
58,
60,
62] has demonstrated high levels of consumer satisfaction. From the early work conducted with adult CSE’s delivered via telepractice, it is recognized that a small proportion of patients will still prefer to attend traditional in-person appointments. However, the majority felt that the telepractice appointment was equal to and could indeed replace the traditional in-person consultation [
47,
100]. Overall, studies have shown that our clients simply want to be given the choice to consider where telepractice can be part of their own care pathway [
16].
Finally, the cost attributed with delivering a clinical service is a key factor impacting sustainability [
92] and must be part of the evaluation of any service model. Telepractice services can be examined with a variety of economic analysis methods [
101] which may include cost-minimization analysis, cost-effectiveness analysis, cost–benefit analysis, and cost-consequence analysis [
92,
102]. In particular, Snoswell et al. [
103] emphasized the importance of taking a broader societal perspective when evaluating telepractice models to enable capture of extra clinical costs such as patient-funded travel or loss of productivity.
The cost advantages of telepractice models have been proven in a number of studies. Wade et al.’s [
92] systematic review of 36 telepractice models that involved an economic analysis, identified that 61% of studies found their telepractice model of care was less costly than the non-telepractice alternative. They also found that a third of the studies demonstrated improved health outcomes using a telepractice model. Specific to the field of dysphagia services, studies have highlighted cost benefits for models that include the delivery of CSE via telepractice with adult clients [
27]. Positive cost benefits have also been reported for telepractice models supporting patients with HNC [
33,
104]. There are also positive data for asynchronous therapy models. Wall et al. [
105] undertook an economic analysis of a randomized controlled trial comparing the delivery of a prophylactic swallowing therapy program via (1) an asynchronous telepractice app,
“SwallowIT”, versus (2) clinician-directed in-person therapy and (3) patient self-directed therapy without the app. Findings confirmed that telepractice was the most financially viable model of care, demonstrating higher
cost-efficiency than in-person therapy (with total cost saving to health service and patients of $1901 AUD per patient). The
SwallowIT model also proved more
cost-effective than patient self-directed therapy, yielding clinically significantly superior QoL at the end of treatment, for comparable costs.
Positive cost savings have also been reported regarding with pediatric telepractice feeding services. Clawson et al. [
54] identified that their telepractice appointment saved families $899 USD per appointment due to avoidance of travel-related costs, and the telepractice appointment also saved parents 1.5 days away from their usual duties. In Clark et al.’s [
106] study, the authors estimated fuel cost savings of $375 USD per family for their 10-appointment series. Similarly, Raatz et al. [
30] identified significant time and cost savings (average AUD $95.09 per appointment) associated with their telepractice appointment model for families who lived in close proximity to their feeding service (within a 40 km radius).