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management services for an individual with dysphagia following chemoradiotherapy?” Searching for the evidence You don’t have access to database searches via your office desktop so the hospital librarian assists you to run searches through PubMed, CINAHL, PsychINFO, the Cochrane library, and SpeechBITE TM . In your search terms you use * to truncate terms, – e.g., swallow * (note: some databases use $ instead of * to truncate words eg., swallow $) – to indicate to the search engine to find words with those first letter strings (e.g., swallow , swallows , swallowing ). When you try using tele * to cover all possible telehealth terms you find over 600 hits with the majority not relevant due to unrelated words, e.g., telephone . Hence you proceed using all telehealth terms you know linked by or (NHMRC, 2000). Your final search term looks like this: ( dysphagia OR swallow *) AND ( telecare OR telemedicine OR telehealth OR telerehabilitation OR telepractice ). You limit you search to English papers only. Your searching provides the following results: PubMed = 17, CINAHL = 9, PsychINFO = 4, Cochrane = 0, and SpeechBITE TM = 0. After removing duplicates, erroneous hits, and excluding papers determined as unsuitable, you find you have a list of 13 possible papers. On return to your office you run a final search in Google Scholar from your work desktop using the advanced search builder. This produces 589 hits. All 13 papers found in the databases were located on the first few pages of Google Scholar search, and a further 7 possible articles were located. A further 10 pages (at 10 hits per page) were scanned. When no further new scientific literature was identified the search was terminated. After reading the 20 publications you found, 7 were subsequently excluded as they either (a) were general discussion papers, (b) covered aspects of telehealth practice other than speech pathology, (c) discussed the use of technology for remote assessments for other scientific purposes, not telerehabilitation, (d) did not involve adult patients, or (e) neither the publication source nor year of publication could be verified (Internet document). This left 6 general review papers and 7 scientific papers. Cross searching of the reference lists of these papers revealed one further paper for consideration. As the review papers were general discussions of the literature, were not systematic reviews, and contained all articles you had found, these were ultimately excluded, bringing your total set of papers for review to 8. Of these, there were 3 papers specifically related to studies using telehealth to assess and manage H&N cancer populations. A further 5 papers were specific to swallowing management via telehealth for other clinical populations; however, only 3 of these were relevant. The others related to the equipment (Perlman & Witthawaskul, 2002) and then the application of remote MBS assessments of swallowing (Malandraki, McCollough, He, McWeeney, & Perlman, 2011). As performing remote MBS is beyond the nature of the service you are considering right now, these 2 papers were not included in your review . Table 1 lists the 6 papers relevant to this review. Using the NHMRC matrix for evaluating a body of evidence (NHMRC, 2009) you classify the body of evidence in Table 1 in relation to your clinical question as follows: Evidence base – good; Consistency – good; Clinical impact – satisfactory; Generalisability – satisfactory; and Applicability – good. Furthermore, your overall decision

videoconferencing equipment (with standard single fixed adjustable zoom camera) available to use and that similar equipment is available at the regional setting. With the answers to your initial questions largely positive, you now seek the evidence for providing telerehabilitation. You need evidence for two reasons. First, you need evidence to justify this alternate mode of service delivery to your line manager. Second, you are seeking information from the literature to inform how best to deliver the service. Developing an answerable clinical question You begin by using the PICO framework to develop your clinical question (Sackett, Richardson, Rosenberg, & Haynes, 1997). This involves considering the Patient or Problem, the Intervention, any Comparison intervention, and specific Outcomes you are seeking (Asking a good Question PICO: http://www.usc.edu/hsc/ebnet/ebframe/ PICO.htm). Studies have found a trend for higher percentages of relevant citations found when searching using PICO formatted questions (Schardt, Adams, Owens, Keitz, & Fontelo, 2007). Patient or problem Your actual specific “patient/problem” group is H&N patients with dysphagia following chemoradiotherapy. However, you are aware that telerehabilitation is a relatively new area of service delivery for speech pathology and the chances of finding data on this particular subset of patients are remote. Hence you feel it is more beneficial to further widen your “patient/problem” group to patients with dysphagia to ensure you access all relevant literature, then narrow this down further to the H&N clinical subgroup if evidence is available. Intervention In this situation, you are not necessarily examining an intervention but rather a model of care, hence your “intervention” in this case is telerehabilitation. In this emerging field of technology, many terms are used to describe the provision of health services through a remote manner. Although telerehabilitation is the specific term used to deliver rehabilitation services via technology, not all studies use this term. For instance in policy documents of the American Speech Hearing Association (ASHA) the term “telepractice” is the adopted terminology (Brown, 2011). As such, it will be important to search all main terms used in this field such as: telehealth, telemedicine, telepractice, telecare, and telerehabilitation. Comparison intervention The comparison intervention is traditional face-to-face (FTF) practice. Outcomes The standard for evaluating a tele-service is to ensure that the quality of the services delivered via this modality are comparable with those delivered via traditional FTF services (American Speech-Language-Hearing Association, 2005). Hence, the outcome you are seeking in your evidence search is whether or not dysphagia services can be delivered via telerehabilitation, and to standards comparable to traditional clinical practice. Clinical question In light of the considerations above, your clinical question for this scenario is “Can telerehabilitation be used to provide

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