Development of an Electronic Documentation System for of an Electronic Documentation ... Development of an Electronic Documentation System for Voice ... with the recently proposed taxonomy and unification ...

Download Development of an Electronic Documentation System for of an Electronic Documentation ... Development of an Electronic Documentation System for Voice ... with the recently proposed taxonomy and unification ...

Post on 07-Apr-2018




2 download


  • Seediscussions,stats,andauthorprofilesforthispublicationat:























  • Perspectives of the ASHA Special Interest Groups

    SIG 3, Vol. 1(Part 2), 2016, Copyright 2016 American Speech-Language-Hearing Association

    Downloaded FromTerms of Use: htt

    Development of an Electronic Documentation System forVoice Therapy: A New Teaching and Clinical Research ToolElizabeth S. Heller MurrayDepartment of Speech, Language, and Hearing Sciences, Boston UniversityBoston, MA

    Katherine L. GirouardDepartment of Biomedical Engineering, Boston UniversityBoston, MA

    Meredith J. ClerGraduate Program for Neuroscience, Boston UniversityBoston, MA

    Cara E. Stepp

    Department of Speech, Language, and Hearing Sciences, Boston UniversityDepartment of Biomedical Engineering, Boston UniversityDepartment of Otolaryngology Head & Neck Surgery, Boston University School of MedicineBoston, MADisclosureFinancial: This work was supported by grant DC012651 from the National Institute on Deafnessand Other Communication Disorders (NIDCD). Cara E. Stepp is an assistant professor at BostonUniversity. Elizabeth S. Heller Murray, Katherine L. Girouard, and Meredith J. Cler have norelevant financial interests to disclose.Nonfinancial: Elizabeth S. Heller Murray, Katherine L. Girouard, Meredith J. Cler, and Cara E.Stepp have no relevant nonfinancial interests to disclose.


    : http://pp://

    Although research on the outcomes of the treatment of voice disorders is widely discussed,there is a lack of information regarding the specifics of the methods and tasks undertakenduring the therapy sessions. One reason may be a lack of a clear, standardized methodof documentation for the voice therapy. Therefore, this article discusses the development ofa new electronic documentation system for voice therapy. The goals of this documentationsystem are to create a user-friendly, flexible system that implements the standard terminologyand structure proposed in the recent voice therapy taxonomy (Van Stan, Roy, Awan, Stemple,& Hillman, 2015). This documentation system stores all the information from the therapysession in a local database, which is accessible for analysis within or between patients. Thisallows large-scale datasets to be compiled for future clinical research. This documentationsystem includes definitions for all terminology and includes hierarchies, which are notrequired, but can be followed for additional structure. This documentation system can beused as a teaching tool, with the ability to accommodate the needs of both the novice andexpert clinician.

    Much of the current research on the treatment of voice disorders focuses on the outcomeof voice therapy. However, unless discussing a new voice-specific therapy method, the details ofvoice therapy are often not explicitly addressed. Without documentation of the methodologies and

    63 by a ReadCube User on 07/06/

  • Downloaded FromTerms of Use: htt

    tasks undertaken in an outcome study, it is difficult to clearly state which elements of voice therapymay have contributed to any changes in vocal function. This not only poses difficulty in terms ofresearch repeatability, but clinically, this hinders the ability of expert and novice clinicians alike toeffectively utilize and learn from evidence-based practice.

    One possible explanation for the lack of details regarding voice therapy in many of thecurrent articles is a lack of a standardized documentation system for voice therapy. Thus, theaim of our current project was to design an easy-to-use and flexible voice therapy documentationsystem. The goals of this documentation system were three-fold: (1) to allow the user to documentthe contents of every voice therapy session, (2) to provide a venue to compile information aboutthe contents of therapy sessions across multiple patients into a central location, and (3) to provideadequate information to allow the documentation system to be used as a teaching tool for noviceclinicians.

    This paper delineates the development of this new voice therapy documentation system.After initial development, the documentation system terminology was adjusted to be consistentwith the recently proposed taxonomy and unification of the voice therapy nomenclature (Van Stan,Roy, Awan, Stemple, & Hillman, 2015). All items listed below in italics (sample) are consistentwith the definitions in the proposed voice taxonomy (see Van Stan et al., 2015 for all definitions).Portions of the documentation system that were not related to the voice taxonomy or not discussedin the voice taxonomy paper are clearly indicated with text that is italicized and underlined (sample).The first iteration of this documentation system was a paper version, which was piloted by alicensed speech-language pathologist (SLP) with three individuals with voice disorders. Followingthe pilot study, the paper version was refined and converted into an electronic version. This articlediscusses the development of the paper documentation system, a case-series utilizing the paperdocumentation system, a qualitative evaluation of the initial system, explanation of refinements tothe electronic documentation system, utility of the documentation system, and future directions.

    Development of the Documentation System

    The original version of the documentation system included a pre- and post-therapy voiceevaluation based on the recently proposed standards for a voice evaluation (Awan et al., 2015).Although the nature of this article precludes a detailed discussion of voice evaluations, thesystem is designed to be compatible with both pre- and post-therapy evaluations. The overallstructure of the documentation system is outlined in Figure 1, including both Direct Interventionand Indirect Intervention.


    : by a ReadCube User on 07/06/2016p://

  • Figure 1. Documentation System Flow Chart. Boxes between the dotted lines are included in thedocumentation system.

    Downloaded FromTerms of Use: htt

    Indirect Intervention

    Documentation of Indirect Intervention is structured to provide the opportunity to recordinformation regarding both Pedagogy and Counseling. Pedagogy includes (1) Vocal Hygiene and(2) Knowledge Enhancement. Counseling includes (1) Therapeutic Interaction, (2) Stress Management,and (3) Coping Strategies. Based on the guidelines proposed by Stemple, Glaze, and Gerdeman(2000), a Vocal Hygiene Hierarchy is included. The clinician is not obligated to follow or use thehierarchy; however the documentation system provides space to record the following if desired:(1) identify the aberrant behavior, (2) describe the effects of the behavior, (3) define specific


    : by a ReadCube User on 07/06/2016p://

  • Downloaded FromTerms of Use: htt

    occurrences of the behavior, and (4) discuss a plan for modifying the behavior, eliminating thebehavior, or modifying the environment (Stemple et al., 2000).

    Direct Intervention

    Documentation of Direct Intervention includes the selection of goals, the modality ormodalities implemented to target the goal (i.e., Direct Intervention Method), the specific Tool used,the level of stimuli (e.g., two-syllable words, phrases), and the Intervention Delivery Method. In theremainder of this article, the Task will indicate a combination of the selected Direct InterventionMethod, Tool, Stimuli Level, and Intervention Delivery Method. All Direct Intervention Methods,Tools, and Intervention Delivery Methods are consistent with the terminology and definitionsproposed by Van Stan et al. (2015). However, at all points in the documentation system, thereis always an option to choose Other, allowing full autonomy on the part of the clinician.

    The five Direct Intervention Methods in the documentation system are: Somatosensory,Auditory, Respiratory, Vocal Function, and Musculoskeletal. Each Direct Intervention Method iscomprised of descriptive categories (see Van Stan et al., 2015 for full details). For example, theSomatosensory method includes the descriptive categories Discrimination, Nociception, and VisualProcessing. Each descriptive category contains suggested Tools. For example, the Discriminationcategory includes Videos, Drawings, and Mirror Use. It should be noted that some Tools belong inmore than one category or under more than one Direct Intervention Method. For example, PitchChanges is a Tool that is categorized under the Direct Intervention Methods of Auditory and VocalFunction.

    Following the selection of the Direct Intervention Method(s) and Tool(s), the cliniciandocuments the stimuli level from the Stimuli Level Hierarchy, which ranges from no stimuli toemotionally/motivating spontaneous speech. The clinician is not required to follow the StimuliLevel Hierarchy, and can use any level of stimuli at any time. Therefore, methods of voice therapywhich do not use a hierarchy and focus more on conversational speech (e.g., Gartner-Schmidtet al., 2015) can still be documented with this system. The clinician then selects the InterventionDelivery Method, which encompasses the structure with which the clinician chooses to deliver theintervention Tool (Van Stan et al., 2015). The documentation system orders the 11 InterventionDelivery Methods into an Intervention Delivery Method Hierarchy, which moves from extrinsicclinician-applied methods, to a combined extrinsic/intrinsic approach, to intrinsic, patient-applied methods. Similar to the Stimuli Level Hierarchy, the clinician is not obligated to followthe suggested hierarchy and can use any Intervention Delivery Methods at any point.

    Case Series: Piloting the Initial Paper Documentation System

    A certified SLP and two graduate student interns piloted the paper version of thisdocumentation system with three patients Pt1, Pt2, and Pt3 (all female, M=25 years old). Allthree patients were seen in the Boston University Academic Speech, Language, and Hearing Centerfrom Fall 2014 to Spring 2015. Two patients (Pt1 and Pt3) had diagnoses of muscle tensiondysphonia and one patient (Pt2) had a diagnosis of vocal fold nodules; all diagnoses were madeby a laryngologist prior to the start of therapy. The clinician used the paper documentationsystem for 6 weeks of voice therapy. Voice evaluations were completed before and after 6 weeksof voice therapy. P...


View more >