TeleAudiology: Virtual Care for Hearing Loss

In 2021, most hearing aids can be adjusted remotely, from the comfort and safety of your home. It's easy to connect with an audiologist through video-conferencing services like Zoom, to discuss your experiences and receive intimate private counseling. And there are even direct-to-consumer hearing aids that can be purchased over the internet, with follow-up services provided remotely by licensed hearing healthcare practitioners.

Over the next few episodes, we’ll explore how new telehealth technologies in audiology might help you on your own personal hearing journey. In today's episode—the first in our telehealth mini-series—we talk to Dr Cliff Olson about the growth of telehealth during the COVID-19 pandemic. We also talk to Dr De Wet Swanepoel, a Professor at the University of Pretoria (and founder at hearX Group), about how scientists are overcoming hearing healthcare accessibility challenges in Africa with the aid of new telehealth technologies. And more!

Podcast transcript

Steve Taddei: Forms of remote healthcare have been explored for many decades. In fact, the National Aeronautics and Space Administration pioneered an early form in the 1960s. Technology has advanced quite a bit since then, and the Covid-19 pandemic has accelerated our efforts to adopt more effective forms of remote care.

We see this in hearing healthcare as well. We now have the ability to program hearing devices from the comforts of your home, we can video conference to discuss experiences, there are even direct to consumer hearing devices — changing the traditional model completely. These advancements all serve to reduce barriers and improve accessibility. Over the next few episodes, we’ll set out to explore the ins and out of these technologies and how best they can help you on your hearing journey.

Teleaudiology, and remote care, bring about many questions. For example, are at-home tests reliable, is video conferencing as effective as just going to the clinic, and can these types of appointments replace in person visits entirely? To help answer these questions, I spoke with an audiologist who’s been using remote care technology for many years.

Dr. Cliff Olson: We actually were using a lot of telehealth before the pandemic started. Manufacturers have been putting this capability inside a lot of their hearing aids for a couple of years now at least. And we made the decision of activating it, even if we didn't think that we were going to have the potential of using that platform to have a remote session with our patients when they're at home and we're in the clinic

Steve Taddei: That’s Dr. Cliff Olson. He’s an audiologist and owner of Applied Hearing Solutions in Phoenix Arizona.

Cliff Olson: It ended up paying off during the pandemic to be quite honest with you because there were occasions where you literally could not have a patient come into the clinic. And we could have at least a remote session to kind of fill in the gap for that time period. It allows us to have additional touch points to kind of enhance the in-person care that we have.

Steve Taddei: We’re all familiar with the typical appointment where you visit a doctor's office. So before we dive into telehealth, I asked Dr. Cliff to discuss how these in-person visits can benefit someone with hearing loss.

Cliff Olson: In-office is really, really nice because we're not limited to any capacity in terms of provision of care. If someone comes in and they're concerned about like “I'm not hearing as well as I was, since my last appointment” we end up going through a checklist of, okay well, is it the hearing aids that need maintenance? Is it, they don't need maintenance, but we got to run a diagnostic check to see if they're mechanically functioning the right way with text box measures. And if that's not it, it's like well shoot, maybe they're hearing actually changed. So we can take them into the test booth and test their thresholds. Well, their thresholds haven't changed. Well, we need to do word recognition to identify if they actually had a decline in speech intelligibility.

We're not limited in any sense of the word when someone comes into the clinic to allow us to do those things. We can always identify the problem and get the problem fixed.

Steve Taddei: In-office visits are great but do have their limitations. Even without a pandemic, transportation and being able to physically get to a clinic can be a challenge. For some it isn't possible due to distance and or other health issues.

This is where we start seeing the real need for telehealth.

Cliff Olson: The other side of it is from a telehealth perspective. The pros of that is that you have a really convenient way to have a quick touch point with a patient, or have a long distance touch point with a patient.

You can make programming adjustments, you can check the data on hearing aids to make sure that they're wearing them, see what types of environments that they're going into which can help lead to the counseling benefits that come along with having a virtual session, just like you would with an in-person session.

And then you had the negatives though of remote care, which is, you know, you're limited in terms of what things you can identify that are not going well. It's hard to run a diagnostic. There are some manufacturers who allow you to run kind of like a little troubleshooting diagnostic on the devices. And I can't tell you how many times I’ve tested that in-office and it comes out inaccurate.

So you can't necessarily trust that virtually. And you run into the aspect of, well, if it's physical care and maintenance that you need to do, it's hard to identify. Especially with the resolutions that a lot of these platforms have. You don't have the ability to really see teeny tiny microphone ports and see if they're being obstructed by earwax, or debris, dead skin cells, things like that.

And then I cannot actually do the fixing myself is the other part of it.

Steve Taddei: This is a good point, even if you can diagnose the issues remotely, it doesn't mean you can fix it remotely. Audiologic facilities have specialized tools and numerous replacement parts.

Beyond that, hearing aids are programmed based on your individual hearing profile. Though many hearing aids can perform an on-ear, or in-situ, threshold check — it's a far cry from what can be done with calibrated equipment in a sound treated room.

Cliff Olson: You cannot do a full-on trustworthy diagnostic test with in-situ audiometry when you don't know what the noise levels are in their environment, you can't do speech testing through that to any reliable degree. So it's really hard to identify if they're having additional decline in hearing or not, or if it's just maintenance that's needed by the device. And then from a test box measure, diagnostic perspective, you can't do that either.

There's pros and cons to both sides but like I said before, I think it's viewed as an enhancement aspect. Which I think is incredibly, incredibly valuable. Especially at least in my clinic, I can speak from personal experience that we have patients who don't live in the same state. Some of them don't live in the same country and we can still provide them with at least some level of care.

Steve Taddei: So far we’ve been discussing the traditional hearing care model. Offering both in-person and remote care or telehealth. There are some companies though that are taking a direct-to-consumer route. Meaning they'll sell hearing devices directly to you, without you ever needing to visit a brick and mortar office.

Devices like this are not new and they’re definitely enticing due to cost and convenience. Some of these companies offer virtual visits where you can still speak with a hearing specialist and receive help with fitting and troubleshooting.

So who are these devices for and how is the quality of care different from the traditional model of hearing care that we’ve discussed so far?

Cliff Olson: From an accessibility standpoint, these companies are filling a need inside of the marketplace for individuals who have hearing loss. That being said, just like there's negatives from a fully in-clinic model, there are definitely negatives from a fully virtual model. Whether there is a hearing care provider involved in that delivery process or whether there's not a hearing care professional involved in that delivery process.

I've been doing virtual sessions for over two years at this point regularly. I know that I have massive limitations when it comes down to doing things virtual and I even have the benefit of having tested these patients in the clinic before. And then professionally fitting them following best practices, like conducting real ear  measurements, doing test box measures to make sure that hearing devices are fit and programmed properly.

Steve Taddei: Dr. Cliff just mentioned that some of these direct to consumer products do not include a hearing care provider in the fitting process. For these self-fit devices, you only receive guidance through the app prompts and user guides. This raises many questions on the quality of fit, and whether they can rival a traditionally fit hearing aid.

Cliff Olson: When you get into these other companies where it’s self administered, there's at least one study out there that was kind of conducted by Bose to show that there's equivalent amount of benefit with their self-fitting hearing aid compared to a professionally fit hearing aid. So there's that out there, but again, now you don't even have the involvement of some of these companies to even have someone to call and say “Hey, am I actually doing this right?”, “Is this hearing test that I did, is this valid?”, “Is the benefit that I'm getting right now with this device, is this the best that I can get out of this device or am I missing something?”. There's a lot of aspects here that are tossed up to the unknown. And I think that we're going to be going through hopefully here in the next couple of years, a really nice kind of experience of what it ultimately is going to mean for the end user who has hearing loss.

I will say that I did not achieve fully accurate results with any product that I've tested. And I've yet to find one that I'm like, wow, they nailed it. There are a few out there that I've been able to get pretty close to the prescriptive targets to the point where I’m like that's respectable for sure. Especially at a lower price point of what these products are selling at. But then we run into issues with feedback. They just don’t have the feedback cancelation algorithms that a lot of the more major manufacturers do to kind of counteract the negative, to get all the positive out of these devices

Steve Taddei: Major hearing aid manufacturers conduct research to verify that the processes in their devices are to your benefit. For example, when they introduce a new directional microphone feature with digital noise reduction, research backs that it can improve the user experience. Furthermore, academics, and other unbiased sources, conduct tests and publish data on hearing aids, user benefit, and auditory processing. Beyond that, part of an audiologist's job is to verify that the devices you wear are optimized to benefit you. This is why we use questionnaires and perform things like real ear measurements and functional testing.

Hearables and other direct to consumer devices don’t always have these cross checks. We don’t know how accurate the in-ear hearing test is, we don’t know if their noise reduction features are of any benefit, we don’t know if they’re accurately applying gain for your hearing loss. Lastly, an audiologist isn’t there to verify that the devices are working and validate that they’re actually helping you hear better.

Now don’t get me wrong, these devices can be great and they have the potential to help people for a fraction of the cost of traditional hearing aids. By design they can outperform hearing aids in some specific situations — such as music sound quality. But it’s important to consider the risks of removing research, comprehensive hearing tests, and hearing specialists from the equation.

Cliff Olson: You always have the risk that everyone likes to talk about which is when you don't have a full diagnostic test battery done on you, you're potentially missing a serious medical condition related to your ears.

Steve Taddei: This can range from an ear infection to various forms of tumors that are associated with your hearing system.

Cliff Olson: You're also running the risk of trying to use a hearing aid when you've got a big plug of wax in your ears. You might not even need a hearing aid, but there’s no one is there to actually look in your ears and see, oh, we just need to do some cerumen removal. We don't know from a speech and noise perspective, to know how well someone would expect to perform in a background noise situation. And for that matter, we don't even know what their speech intelligibility is, even if they do amplify sound for themselves.

So when it comes down to actually then using a direct to consumer product, if they're not getting benefit, is it because the device isn’t giving them better or is it because literally their hearing is not capable of receiving benefit from one of these devices?

The whole direct to consumer model is based on the “good enough” model. They know that they can't reach perfection with it. They're not trying to reach perfection with it. They're trying to give benefit to their users and enough to justify the price point that they're charging. And I don't honestly think that there's anything wrong with that at all.

I think the most dangerous thing though, with this direct to consumer is this idea that if someone does not perceive benefit with these direct to consumer hearables or hearing aids, whatever you want to call them.  If they say “Oh, hearing devices just don't work for me”, that's where we're really dangerous. Because we don't know if that is in fact, the case. We don't know if it's a medical issue. We don't know if those devices just weren't the ideal devices for you. But if they end up giving up on hearing treatment, because they tried the cheap option that they thought they would get more benefit out of and they didn’t and they just chalk it up to, oh, I just don't get benefit with hearing aids. There's potential that we could see adoption rates drop below 30 percent in the United States and potentially other countries as well.

Steve Taddei: There are clearly lots of considerations with telehealth and direct to consumer hearing devices. Our discussion so far has just scratched the surface.

To get a better understanding of teleaudiology and how it can help people around the world, I spoke with Dr. De Wet Swanepoel who’s played an integral role in developing and integrating telehealth through the company HearX for lower socioeconomic regions of the world.

Dr. De Wet Swanepoel: HearX is a digital hearing health company with a vision of healthy hearing for everyone everywhere. So it's really a social enterprise at heart. And the mission that HearX has is really to provide affordable access to hearing care using these smart digital health solutions that anyone can use anywhere

Steve Taddei: That’s coming up after the break.

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As we’ve been discussing, there is much controversy surrounding telehealth and remote care appointments. However, it’s important to consider that not everyone has access to an audiologist and proper hearing care. What if you live in a small town or rural area? Beyond that, not everyone lives in a higher-income region, where healthcare is readily available.

De Wet Swanepoel: Audiological care is extremely limited.

Steve Taddei: Dr. De Wet Swanepoel is a hearing scientist and professor of audiology at the University of Pretoria in South Africa.

De Wet Swanepoel: We’ve been forced to innovate, to try and find solutions to this access issue. I mean, less than 3% of people who need hearing aids in a continent like Africa are able to access them. And there's about one audiologist to every million people on the continent. So you can just imagine the disparities just are overwhelming and that's really kind of fertile ground for innovation

Steve Taddei: De Wet and his colleagues wanted to improve healthcare accessibility, so they looked at the technologies available and various trends. What they found, might surprise you.

De Wet Swanepoel: Smartphone penetration is tremendous across the continent. The connectivity you know, 95 percent of people have access to a mobile phone signal.

Steve Taddei: This level of connectivity provided a platform for mobile and remote care. From this, they founded HearX back in 2015.

De Wet Swanepoel: HearX is a digital hearing healthtech company with a vision of healthy hearing for everyone everywhere. So it’s really a social enterprise at heart. And the mission that HearX has is really to provide affordable access to hearing care using these smart digital health solutions that anyone can use anywhere.

I think one of the unique things about HearX is that it’s a spin out from a university. So everything that it does is really validated.

Steve Taddei: This level of research helps alleviate some of the concerns we discussed earlier with Dr. Cliff. So what are some of the technologies that HearX offers?

De Wet Swanepoel: We produce medical digital devices for screening and diagnostics on mobile and online platforms.

That's really to support the hearing health industry profession, audiologists, to use these technologies to decentralize their services outside of traditional clinics. So the whole idea is that it's mobile phones, a smartphone or tablet, based solutions where we can do pure tone audiometry.

It's typically not the kind of pure tone audiometry that you’d do in a booth. So very user-friendly, simple user interfaces, that a facilitator can capture information on. And then it's automated testing. Whenever you do these kinds of audiological testing outside of typical clinic environments, you also have to be sure that you're doing significant quality control because oftentimes it's not an audiologist facilitating the test, but you're also not in ideal situations.

So we rely on the sensors of these devices to inform the test procedure. So for example, we continually monitor the environmental noise with the microphone of the device. We also do quality control tracking on things like false positive responses. So we track the number of false positive responses, we compare that to a large database of a couple of hundred thousand tests, and if it's outside of the normal range we can flag that as a concern. And then things like response times, and all of these things. So it's very much data driven to ensure that you can provide a quality validated assessment outside of traditional settings, facilitated by someone with minimal training.

Steve Taddei: All these audiologic tools are integrated into a cloud based system. This means that everyone has quick access to results and important medical information.

De Wet Swanepoel: We have screening versions of the diagnostic testing that can be used on a mobile phone. And based on the geolocation that the screening has been done, a text message can automatically be sent, for example, to the parent with the results of that screening immediately. So it gives that immediacy. It also allows for reporting, quality control, and surveillance.

Steve Taddei: A hearing screening or more diagnostic assessment doesn’t always give you the full picture. It’s best practice to look in the ears prior to any testing when possible. This is called otoscopy, and while it might seem difficult to do this accurately from afar, HearX is working on a solution for this too.

De Wet Swanepoel: One of the exciting little digital projects we have as well is something called HearScope. That's a digital otoscope the size of a pen. It plugs into the mobile phone, or the tablet, and it does amazing digital video otoscopy. So you can get really clear wide angle images of the eardrum and ear canal.

But what's really exciting is it includes the first AI classification of the eardrum. So we've developed an AI classification tool over the last five years. We have a massive database where we've trained a machine learning algorithm and we're now in our fourth iteration of it.

We support otitis media, we've got perforation of the eardrum, we've got a category of chronic suppurative otitis media, wax impaction, and then we also have normal obviously you need that. And then we’ve got a group category of abnormal, where we've kind of put in all the other pathologists like cholesteatomas as an abnormal category requiring referrals. So that category we're expanding as we get enough images to support these other less prevalent conditions

Steve Taddei: In case you’re not familiar with some of those terms, otitis media is a middle ear infection, perforation refers to a tear or hole in your eardrum, and cholesteratoma refers to an abnormal collection of skin within your ear. HearScope and its artificial intelligence classification system, are in the final stages of FDA verification and it has already been used in over 85 countries.

De Wet Swanepoel: In Africa, you know it’s the only diagnosis that you’re going to be able to get. So it’s exciting what these digital tools enable. So if you incorporate all of these inputs together, you have a very comprehensive view of someone's test results.

Steve Taddei: Another popular screening tool is online hearing tests. I’ve tried a few of these myself and they really range in style and quality. De Wet went on to describe an online screening tool provided through HearX.

De Wet Swanepoel: Something that Covid-19 has kind of, you know, pushed to the forefront and that's online hearing this thing. So we also provide an online hearing test that audiologists can plug into their website very easily.

It uses a digits in noise technology, which is the only validated online hearing test in the world at the moment. So we have a long list of validation papers on this extremely accurate test. Because you're online, you can't use calibrated headphones, right? So you need to rely on a test that’s not reliant on calibration like pure tone audiometry.

Steve Taddei: As De Wet just mentioned, standard pure tone threshold tests involving these [beep beep beep] required sound treated rooms with calibrated systems and speakers. A digits in noise test is more of a hearing screening, but it can be performed accurately on any device or headset as it uses the ratio between speech and noise to calculate results. For example, this is what it sounds like [static noise with voice saying three numbers]. Could you hear those numbers? You would then hear more sequences of varying volume based on your response [static noise with voice saying three numbers much quieter]. De Wet and his team at HearX have been working to offer this test globally

De Wet Swanepoel: That test is also the tests that we've developed for the World Health Organization, which has now done close to 300,000 tests globally in every country of the world in fact. Many other big corporations are using that technology like I'm thinking of 23andMe for example. Bose is also using this test on their website as part of their offering for their hearing aids. For audiologists, it's great because you can actually put it on your own website and it's just a wonderful way to keep your clinic open 24 hours a day, virtually because many people are doing these tests after hours.

Hearing healthcare is an industry that is changing, evolving. We, as audiologists, should also look at these changes and really kind of embrace digital health technology as part of our way forward. So my message to the students and to the colleagues that we work with is always that instead of trying to kind of resist these changes, I think we need to find ways of working with these technologies and with these changes. Because we know how important the role is that we play and we just need to be sure that we kind of continue defining that role. Otherwise, other industries will define it for us.

Steve Taddei: In my discussion with De Wet, we talked alot about audiology as a field. And although that last statement was more towards professional, it's important for everyone to hear because the vast majority of hearing care providers are truly dedicated to improving your life and helping you hear better. It's just a matter of us learning to work with these changes so that people like you have better access to accurate timely hearing care.

A big part of that though is accessible validated hearing devices, at more affordable costs. There is an entirely different division of HearX that we have yet to discuss.

De Wet Swanepoel: …and that’s where we’ve kinda combined these technologies into a platform where we can also provide amplification, or hearing aids, through this platform directly to consumers. That’s the newer division, and of the businesses under that is called Lexie Hearing.

Steve Taddei: Tune into next month's episode to learn about Lexie Hearing, other alternative amplification devices, and a new innovative patient centered hearing care approach.

Steve Taddei: I'd like to thank Dr. Cliff Olson for sharing his telehealth insights and clinic experiences during the pandemic. You can find more information about Cliff, his clinic, and his content by visiting drcliffaud.com. I'd also like to thank Dr. De Wet Swanepoel for discussing the innovative technologies from HearX. He’ll be joining us next month to continue our discussion on Lexie Hearing. You can learn more at hearxgroup.com.

The Hearing Tracker Podcast is hosted by me, Dr. Steven Taddei. This episode was written, produced and sound designed by me with help from Abram Bailey. If you liked today's episode, please consider leaving us a review and share it with someone who needs hearing help. You can find much more helpful content and keep up to date by visiting us at hearingtracker.com. As always, thank you for listening.

Earlier this year, the World Health Organization predicted that one-in-four people will have some degree of hearing loss by the year 2050. There aren’t enough providers to meet the growing need for hearing help.