Friday, October 14, 2011

Will Apple's 'Siri' Bring Voice-Control Into the Mainstream?

Many critics were disappointed at the lack of any iPhone 5 announcement from Apple, and whilst there is no flashy new design for the exterior, the iPhone 4S has a number of major new features. One of the main features being touted was Siri, a voice-controlled software assistant. Siri allows you to interact with your phone using just your voice. It can set calendar events, even checking for schedule conflicts, it can check weather and stock reports and find answers to questions using the powerful computational knowledge engine Wolfram Alpha. This seems like an impressive offering, but despite improvements in the technology, speech-recognition has not found it’s way into mainstream products so far, can Apple be the first to achieve widespread adoption?

Speech recognition is already well established. Most people will have encountered, and probably been infuriated by, voice recognition in automated telephone support systems. But voice recognition is also an important assistive technology. Both Microsoft Windows and Mac OSX operating systems have extensive built in voice control and screen-reading systems to allow all functions to be automated via voice commands.

Nuance’s speech recognition software ‘Dragon Naturally Speaking’ is the main choice, and has advanced dramatically over the last decade. Several years ago, their dictation software required a lengthy calibration session of an hour or so to allow the system to learn the user’s voice; today, you can use their free mobile app to dictate text messages and activate functions with no calibration required whatsoever.


 But figuring out the actual words that have been spoken is only the first part of the challenge. The spoken words must then be interpreted into some kind of query or command that the computer can understand and then act on. Making sense of natural language, with all it’s ambiguities and turns of phrase, has been an incredibly difficult challenge so far.

Recently, IBM’s ‘Watson’ computer software managed to win the popular game-show ‘Jeapardy’, playing against previous show champions. The game show was chosen because not only does it require a great breadth of knowledge, but the questions are often posed using ambiguous or cryptic language. The Jeapardy challenge was a great PR stunt for demonstrating the software, but this marked a significant leap forward, opening the door to natural language communication with machines.

Apple has a long-standing tradition of bringing products and technologies into the mainstream and achieving widespread adoption: the iPod was by no means the first MP3 player on the market, but it’s success quickly made the label ‘iPod’ into a generic term for portable MP3 player; the iPhone was the first touch-screen only device; and the iPad still remains by far the most popular and sought-after tablet despite numerous aspiring competitors. This is not only down to clever marketing, Apple has achieved widespread consumer adoption of their devices for their ‘it just works’ approach to ease of use. Customers trust that not only will their products be easy to use, but they will also work well together.

So can Apple turn Siri into the first major mainstream voice-controlled application? People will have to get used to interacting with their mobile devices in a new way, but if Apple can achieve widespread adoption through it’s products, then this will no doubt drive further innovation of the technology and will see it’s implementation in many more products and applications all around us, and we can all look forward to fascinating conversations with our washing machines and public lifts.

So Cool...Assistive Technology Rocks! Paralyzed man touches girlfriend with robotic hand

Thursday, October 13, 2011

Medicare Funding for Speech Generating Devices

Apps: An Emerging Tool for SLPs

From the ASHA Leader

Apps: An Emerging Tool for SLPs

A plethora of apps can be used to develop expressive, receptive, and other language skills.
see also
Portable electronic devices such as the iPhone, Droid, BlackBerry, and iPad, collectively termed mobile media devices, have changed the way we interact with the world, from social connections to work and entertainment. Speech-language pathologists are not exempt from this "mobile revolution," as the platform has changed the way many SLPs engage clients to meet their individualized goals.
Although there are many mobile devices with application (app) options for SLPs, including the Droid platform, this article will focus on the iDevices, including the iPad, iTouch, and iPhone, as this author has the most experience with this platform. (A list of Droid apps for children with special needs [PDF] created by special education teacher Jeremy Brown is available online.)

It is clear that iDevices are quickly becoming a key tool in our intervention arsenal. The multifunctional, engaging platform allows for a convergence of treatment materials, quick access to incentives, and data collection. The iDevices are relatively inexpensive and available through local retailers or online stores, and apps are affordable and easily acquired through downloads.
However, the unparalleled popularity of the platform—coupled with the speed with which apps are being produced—has resulted in new challenges and responsibilities for SLPs (Gosnell, Costello, & Shane, 2011).

SLPs have always needed to be informed, creative, and critical, but the rapidly changing world of apps and iDevices introduces new challenges for savvy clinicians. Being informed now means keeping up to date with an ever-growing selection of apps created to support speech and language goals.
With creativity, we can maximize the diagnostic and therapeutic "power" of the iDevice platform by using these dedicated apps and the built-in features of the iDevice. Through imaginative client-centered creativity, the SLP may use a broad range of apps not expressly designed or intended to target speech, language, and communication objectives to entice clients to engage actively in and enjoy intervention.

It is also critical that we remember the clinical adage that "no single tool fits the needs of all clients" and that we should always first focus on matching a client's needs, strengths, and skills to the most appropriate tools and strategies (Shane & Costello, 1994). It is imperative that we continue to be critical in our assessment and be aware of the potential mismatch of apps and iDevice platforms to a client's actual needs.

Dedicated Applications

We are entering a new era of tech-savvy kids. Many young children are exposed to their parents' iDevices. Children are able to manipulate and interact with these devices easily and with very little instruction and are engaged in the technologies for long periods. Clinicians can use this interest to their advantage through the many "dedicated" speech applications available through digital marketplaces, such as the iTunes store, including apps for language development, speech/sound production, receptive language, organizational skills, and augmentative communication.

Speech-production apps commonly provide a deck of images targeting phonemes in initial, medial, and final word positions (e.g., Pocket SLP, ArtikPix). In addition, many of the apps have built-in data collection features to support managing many students on a caseload (e.g., PhonoPix). The animations and reinforcement provided for correct answers are an added bonus to an already enticing medium.
Traditional language treatment (expanding mean length of utterance, using various syntax forms, increasing lexical diversity) can still be targeted through apps (e.g., iStory, 60 Story starters). Table 1 [PDF] provides examples of dedicated apps that target goals of spoken language production. (This article includes a number of tables that highlight examples of applications. They are not intended to provide a compilation of all possible apps that could be used for speech-language assessment and intervention, given the prolific, fast-paced, and dynamic worldwide development of apps.)

As with expressive language, many apps target receptive language skills. Receptive skills sometimes require spoken answers, but other times simply require pointing to an appropriate object or picture. Table 2 [PDF] includes examples of apps created to target both modalities for enhancing receptive language abilities. Preposition Remix and Splingo's Language Universe are examples of apps that use a game format, requiring the child to point to or move the appropriate object or picture on the screen. Many apps require the child to "talk out" answers (e.g., if…then) or describe scenes (e.g., "the boy is in the bed…"), and some even record user responses.

Table 3 [PDF] identifies many commonly used augmentative and alternative communication (AAC) applications—apps developed to enhance, replace, or supplement an individual's communication capabilities.

More than 100 AAC applications are available through such marketplaces as iTunes. Websites,
blogs, and Google documents seem to be a common source of information about AAC apps, and often can be used as a first step toward acquiring information.

Creatively Adapting Apps

A search focused only on a specific profile of dedicated apps (speech production, targeted language goals, augmentative communication) could miss many well-designed apps that offer motivating and fun learning opportunities. Using creativity, clinicians can reach beyond an app's intended target audience and purpose and adapt it to support interventions. Apps created for other purposes (e.g., Starfall, created for early literacy skills) could be used to motivate uninspired children to engage in intervention goals such as letter knowledge, phonemic awareness, and decoding skills.

Starfall, for example, was helpful in working with Sophia, a 5-year-old girl with cerebral palsy who vocalizes minimally. Her mother reported Sophia "shut down" in regard to using her voice, refusing to produce any form of sound even when engaged in imitation tasks, co-active movement, or play. When presented with the Starfall app on an iPad during an assessment, Sophia quickly started touching letters while producing sound approximations mimicking the sounds by the iPad.

Like Starfall, almost any app can be transformed into a treatment tool. The free app "Doodle Buddy," for example, created for "painting, drawing, scribbling, and sketching," can be adapted and used to meet many intervention goals. Table 4 [PDF] provides examples of expressive and receptive uses of this app. The examples include common therapy goals (on the left) and images that correspond to an activity or goal (on the right). Although this app was not created for speech-language intervention, a creative clinician use it well beyond its intended purpose to support a variety of expressive and receptive goals and activities.

In the series "from useless to learning apps," SLP Barbara Frenandes details similar examples of using what some may term "useless apps" (e.g., Angry Birds). She highlights how to capitalize on the child's captivation with the app and to conduct a productive, goal-directed treatment session.
Table 5 [PDF] details apps—although not created explicitly to target receptive or expressive goals—that imaginative clinicians can use as a catalyst for participation. They can be used in many different ways (speech production, sequencing, voice feedback, pacing, age-appropriate concepts, following directions, etc.). Potential goals may include following directions (e.g., My Playhome, Cupcake Corner), increasing vocabulary (e.g., Pogg), or sequencing (e.g., More Pizza!). (For more ideas and app lists, refer to Therapy App 411, Geek SLP, and Speech Language Pathology Sharing.) These sites provide lists of apps and examples of ways to use an app to support a variety of expressive and receptive goals and activities.

Using Photo Libraries

Many of the applications adapted for treatment are low-cost. An additional no-cost resource is the use of your photo library. This built-in feature is commonly untapped and easily can be used to support a broad range of activities and interventions (see Table 6 [PDF]). Examples include creating:
  • An "articulation deck" (download photographs that are in the public domain).
  • A photo deck for description (e.g., pronouns).
  • A library filled with photographs for preference indication (an individual can "scroll" through and select photos).
  • An organized photo library with activities specific to individuals on your caseload. Creating photo folders with individuals' names or activities allows easy access to clients' photos during sessions.
  • A sequencing activity or a visual schedule.
  • A photo deck for object, scene, dynamic, and element cues (Shane & Weiss-Kapp, 2007).

App Pitfalls

The iDevice platform is exciting, but it warrants caution because of pitfalls that could affect the course of intervention and impede progress. We are observing shifts away from the SLP being the driving force behind intervention: In some instances families are choosing to "self-treat," and in others the educator or tech department is handing out iPads with preselected apps, requring clinicians to fit their clients' treatment to the available iDevice and apps.

Speech-production apps should not be used in place of speech-language treatment with a certified SLP, nor should use of apps for clinical purposes proceed without training and guidance. Solid clinical judgment and knowledge are required to assess and monitor the efficacy of an app as a clinical tool. Many of the listed apps may be user-friendly, but provide incorrect feedback, such as accepting incorrect sound production responses as correct, inaccurately collecting data, or encouraging the user to ignore function in lieu of drilling on "just any sound" instead of clinically relevant targets.

A comprehensive assessment must be the starting point prior to selecting an iDevice and app or any other tool or strategy. The popularity of the iDevice platform, coupled with the impressive speed with which apps that parallel desirable features of dedicated speech-generating devices are being produced, have resulted in many practitioners forgoing, or at least temporarily suspending, well-established clinical assessment strategies. When SLPs select the iDevice platform and apps without assessments, they run the risk of making decisions without sufficient experience or clinical judgment and knowledge (including awareness of language abilities or needs, other assistive communication device options, and the differentiating features of apps).

A great harm of reckless clinical decisions is the time wasted trying to learn or use an inappropriate communication technology. As a way to ensure appropriateness of apps, clinicians should ask two primary questions: "Were the iDevice platform and accompanying app determined through a thorough clinical feature-matching process?" and "Are we fitting the person to the iDevice and communication app or are we fitting the person systematically to the iDevice?" (Gosnell, Costello, & Shane, 2011).
As responsible SLPs, we should be alert to the overuse and flurry of recommendations for iDevices as they relate to replacing intervention with a certified SLP and dedicated AAC devices. In many cases these devices fall short: the iDevice doesn't provide appropriate feedback, the application freezes, the volume is not sufficient in many environments, the hardware is quite fragile, or access options for those with motor challenges are limited (Farrall, blog 2011). As SLP Jane Farrall states, "I could spend a lot of time trying to ‘make' this technology work for someone when there is a piece of specifically designed technology that will work straightaway."

As we enter this new era of educating and engaging tech-savvy children, providers must continue to learn and challenge themselves to develop more engaging and relevant assessment and intervention strategies. The iDevice platform can be loaded with free and reasonably priced apps that may be used to support work in speech, language, comprehension, AAC, and literacy. Apps can easily be incorporated into treatment and may at times be the most effective support of our intervention goals. But only through informed clinical judgment and a continued demand for evidence can a tool or strategy be deemed the most judicious and effective for a client's needs.

We must maintain an ever-diligent focus on what most motivates and engages a child to demonstrate true competence. Only then can we legitimately incorporate the iRevolution into our arsenal of best clinical practice.
Jessica Gosnell, MS, CCC-SLP, is a clinician in the Augmentative Communication Program in the Department of Otolaryngology and Center for Communication Enhancement at Children's Hospital in Boston. She is a member of Special Interest Group 12, Augmentative and Alternative Communication. Contact her at
cite as: Gosnell, J. (2011, October 11). Apps: An Emerging Tool for SLPs : A plethora of apps can be used to develop expressive, receptive, and other language skills.. The ASHA Leader.


AAC-RERC (2011, March). Mobile Devices and Communication Apps. Retrieved from
Farrall, Jane (2011). Apps for AAC. Retrieved from
Gosnell, J., Costello. J., & Shane, H. (2011). Using a clinical approach to answer "What communication apps should we use?" Augmentative and Alternative Communication, 20, 87–96.
Shane, H., & Costello, J. (1994, November). Augmentative communication assessment and the feature matching process. Mini-seminar presented at the Annual Convention of the American Speech-Language-Hearing Association, New Orleans, LA.
Shane H. C., & Weiss-Kapp, S. Visual language in autism. San Diego: Plural Publishing, 2007.

Health Literacy--do you understand what the doctor is saying??

Health Literacy: Reducing the Burden of a Complex Healthcare System

Nearly 9 out of 10 adults have difficulty using the health information from doctor’s offices, hospitals, online and in the media, according to background in the National Action Plan to Improve Health Literacy. People with low health literacy are more likely to skip medical screenings, end up in the emergency room and struggle with chronic conditions. As more people gain access to preventive services through the Affordable Care Act (ACA), now is a critical time to reduce the burden of complexity in the healthcare system and beyond.

NewPublicHealth spoke with Linda Harris, Ph.D., Health Communication and eHealth Team Lead in the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion (ODPHP) and Cindy Brach, MPP., Senior Health Policy Researcher for the Agency for Healthcare Research and Quality (AHRQ) about efforts to improve health literacy. ODPHP will co-host a Health Literacy Month Twitter chat on health literacy’s role in promoting prevention provisions in the health care reform law. Learn more about the chat and join the discussion on October 20 at 2 p.m. EST, using the hashtag #healthlit.

NewPublicHealth: Tell us about the burden of health literacy and the impact it has on the health of our nation.

Cindy Brach: We have a population that does, by and large, not have the skills needed to function in the current healthcare environment. Only about 12% of Americans, according to national data, are proficient in health literacy. In fact, all of us struggle at one time or another; it may be because we’re sick or we’re stressed or it may be because we have trouble reading or understanding medical concepts, but we struggle with the health information that’s presented to us.
There is a mismatch between the skills that American adults have and the demands the healthcare environment makes on people – to navigate the system, to parse out what is being said to them [by healthcare providers], and to read those dense documents that have critical medical instructions. What we strive to do when we talk about improving health literacy is to not only try and raise individual’s abilities and skills through adult education and other programs, but also to reduce the complexity of the health information and the navigation that is required for patients to be able to get the healthcare they need.

Linda Harris: I would remind us that related to the ACA, about 32 million Americans, half of whom have limited health literacy, will be eligible for free preventive services through ACA coverage in 2014. It’s a very specific population that we’re aiming to assist in reducing their burden, if possible, before the coverage begins.

NPH: What is the role of health literacy in getting the word out about these services and reducing the burden on those looking to get preventive care?

Cindy Brach: We know that health will improve if Americans have access to and use preventive services that have been recommended by the U.S. Preventive Services Task Force. Where health literacy fits into this is that we don’t always do a brilliant job of explaining what is available, why it’s important, what are the relative risks and benefits, and helping people make the decision about preventive services.

Linda Harris: The appropriate use of preventive services is one of the important areas where health literacy improvement really makes a difference. There’s some good data supporting that. Whatever assistance we can provide to help people make good decisions about the preventive services that are right for them is one of the responsibilities we’re trying to take on with our online decision support tool, called myHealthfinder. It helps people who are thinking about preventive services make good decisions about which ones they need, and also the kind of self-care wellness decisions they can make.

NPH: What should the role of different sectors be in engaging people with low health literacy in better health – from physicians to health departments to employers and community organizations?

Linda Harris: As you know, we have produced a National Action Plan for Improving Health Literacy, and that offers a strategic framework that we hope will help all of those stakeholders in health literacy to assume the strategies and tactics that are evidence-based for improving health literacy. We’ve looked to the National Action Plan as guidance for everybody so we can all be on the same page for the kind of system changes each one of these kinds of organizations needs to enact.

Cindy Brach: Certainly in healthcare delivery settings, there are a variety of areas in which we can do a better job. One is in the area of spoken communication – getting that jargon out of what we’re saying, confirming that an individual understands what’s been explained to them, encouraging them to ask questions and engage in shared decision-making. We can also greatly improve our written communication, which is much more than getting the reading level down to fifth grade or focusing on the font size, but really making sure our health materials are understandable and actionable so that after reading them people know what to do or how to make the decision they’re confronted with. We at HHS see this as very much a joint partnership with other public and private organizations. It’s going to take all of us to turn the ship around and to reduce the complexity.

NPH: What is HHS doing to improve health literacy?

Cindy Brach: One of the things we’ve realized is that as awareness of health literacy issues has increased, people are hungry for tools that can help them address their patients’ needs. At AHRQ, one of the tools we’ve developed is the Health Literacy Universal Precautions Toolkit. It’s a series of 20 brief tools that can help better promote understanding by all patients. Another toolkit AHRQ funded is for hospitals to change the process by which they discharge patients. It’s called the Re-Engineered Discharge, or RED toolkit. That toolkit uses health literacy principles to educate the patient throughout their stay, not just in the hour before they’re going to leave the hospital. Discharge educators talk to patients about their condition, the next steps they should take when they leave the hospital, the warning signs, and make it easier for them by making appointments for follow-up care before they leave the hospital. The toolkit includes a template for creating a plan that patients can easily understand called the After-Hospital Care Plan. So rather than a discharge summary full of jargon that patients can’t make heads or tails of, it uses graphics and very clearly puts out the information that they can take home with them and bring to their subsequent appointments. It’s putting the information into the patients’ hands in a way that they can act upon it.

NPH: Is this toolkit in use now? Have you heard back from hospitals that are using it?

Cindy Brach: Yes, it is in use. It started out as a randomized controlled trial where it was shown to reduce rehospitalizations, that is admissions or subsequent emergency room visits, by 30%. Since then, it’s been used in a number of Care Transition programs that are demonstration projects by the Centers for Medicare and Medicaid Services. We’ve also had hundreds of hospitals taken advantage of technical assistance that AHRQ has sponsored to implement the program.

NPH: How are you tracking progress in improving health literacy?

Linda Harris: In collaboration with AHRQ, we are through Healthy People 2020 tracking progress in some aspects of health literacy, specifically the quality of communication between provider and patient. We are essentially tracking how well providers perform the teach-back method [a proven method of ensuring patient comprehension by having patients explain back key concepts in their own words], and we’ll be able to track that over the next decade. We’re looking forward to seeing improvements in that. There are also a number of other related objectives, like prescribing information at the point of service delivery and increasing the meaningful use of electronic medical records – and other objectives that really do support, as Cindy was saying, more the systems view of the need for everybody to make life a lot simpler.

NPH: Anything else to add about health literacy?

Linda Harris: Health literacy is not just a sidebar to improving healthcare – it is integral to transforming healthcare into the kind of cost-effective, high-quality experience that everyone should have access to. One of the ways we describe that is the role of improving health literacy in reducing unnecessary hospitalizations. Health literacy improvement can play a critical role in something that’s really an important healthcare system improvement strategy, including efforts to reduce unnecessary hospitalizations.

Cindy Brach: Hearing the word literacy sometimes gets people focused on grade level and the written word, whereas health literacy is so much broader, encompassing lots of different kinds of communication and navigation. This video from the ACP Foundation has been a real eye-opener for many people, and helps to illustrate that. It’s also important to remember that everyone – regardless of education or socio-economic status – can face health literacy challenges. We as a country are not going to achieve our healthcare goals of improving access and quality while containing costs unless we figure out how to redesign our systems to eliminate these challenges

Sunday, October 9, 2011