Feb 2021 The Hearing Journal

As 2021 begins in full force with optimism for a COVID-19 endgame, economic upturn, and global healing, emerging developments in hearing technology promise a significant impact, particularly on helping audiologists and patients cope with the new normal. From improved artificial intelligence to new mask mode features, to smart earbuds, these developments are transforming hearing care provision—as well as patient expectations—as additional factors, including over-the-counter (OTC) access and diverse device price points, are entered into a complex equation.

technologyTo shed light on this interesting convergence of hearing care provision, technology, and pending regulatory changes, The Hearing Journal (HJ) hosted an online roundtable discussion with leaders from the American Academy of Audiology (AAA), Academy of Doctors of Audiology (ADA), and American Speech-Language-Hearing Association (ASHA). In this month's cover story, we continue our discussion with ADA President Victor Bray, PhD, ASHA's Vice-President for Audiology Practice, Sharon A. Sandridge, PhD, and AAA President Angela Shoup, PhD, along with HJ’s Editorial Board Chair Fan-Gang Zeng, PhD, as the discussion moderator, on optimising advances in hearing technology, including OTCs and personal sound amplification products (PSAPs), to support hearing care professionals and audiology practices this new year.

Dr. Zeng: What recent advances in hearing technology are you most excited about, and how would you incorporate these—including OTCs, PSAPs, and hearables—into your practice? Do you think these advancements are threats or opportunities?

Dr. Bray: My first answer is about audiology in general and separate from consumer electronics. The single and most important update in audiology is the seating of the new congress and resubmission of the Medicare Audiology Access and Services Act, which is jointly supported by ADA, AAA, ASHA, and HLAA. Practitioner status, direct access, and recognition of both diagnostic and rehabilitative roles of audiology are critical to the maturing of the profession and logically necessary to the proper outcome of the AuD degree transition.

More specifically to the question of consumer electronics, there have always been efforts underway to alter or even disrupt the traditional provision of amplification to audiology patients. Personally, as a participant in three different start-ups working in that space, it has always been about disrupting the current models to see if we could bring something better to market—and at times we are able to do that. Certainly, many innovative products today and those on the horizon can potentially change the way patients and consumers access the tools to enable better hearing.

Here's what I am teaching our AuD students to prepare them for the world in which they will practice upon graduation in 2023. Dr. Dillon, a decade ago, described this as “connectivity and convergence.” For example, at present, a person with impaired hearing may be fit with RIC aids, a smartphone with Bluetooth, and a remote microphone. The technology already exists today to use a pair of earbuds as the ear-level device, a Bluetooth smartphone, and an app to reshape the sound for someone with mild to moderate hearing loss, with the smartphone utilised as the remote microphone. ADA has a long history of supporting entrepreneurial activities, and we do not necessarily view the new consumer electronic offerings as a threat. Any change is a potential opportunity to find and incorporate better solutions for hearing care, and we must keep an open mind. An important development is having major companies like Apple and Google contribute to the message that hearing loss is a major health concern. This can help raise awareness that hearing loss must be addressed and not ignored by individuals, families, and our health care system. Any time audiology prioritises the needs of our patients, audiology will win out.

Dr. Sandridge: We have this motto, “Challenges are opportunities to grow.” These challenges to our profession are incredible, great opportunities to embrace. I look forward to incorporating all kinds of OTCs. [At Cleveland Clinic], we are even talking about working with our innovations team in designing our own PSAP so we can have a Cleveland Clinic-branded, very inexpensive amplifier that we can market here at the clinic. There are tremendous opportunities to get on board with all of these developments. As Victor said, anytime you can raise awareness about hearing loss and its impact on health-related quality of life—it's a win-win situation.

The other day, I had a patient come in who had two sets of PSAPs that she bought from Amazon for $37 and $70. And she got what she paid for—they were crap. We ended up getting her into very low-end hearing aids. But why not offer these as an early solution?

Years ago, we put together a questionnaire, which we recently redesigned with questions for patients, including, “Do you want to be a part-time user?” and “Do you want to just use this occasionally?” With this questionnaire, you can create a perfect avenue to offer patients with inexpensive units that they can use occasionally to just get them started [with amplification]. And when they want to use amplification full-time, you can offer them other routes. If we don't embrace them, then we are not going to be providing our patients with the whole continuum of care.

It is also an exciting time because there are so many options. The biggest challenge I see is trying to find which device to embrace and bring in. There is no reason why we can't bring in Apple AirPods and Bose products, for example, and sell them to make it convenient for the person to purchase it right there and then from us. The options are limitless, and the opportunities are there. We just have to put it in our business plan and go for it.

Dr. Shoup: Advances in technology that can offer additional benefits to patients are always an opportunity to positively impact their quality of life. However, I do think these do not replace the critical role of the audiologist. In many cases, there is an increased need for the person to have access to knowledgeable skilled providers who can review the many options and identify those best suited to meet the individuals’ hearing care needs.

It is one thing to take AirPods, for example, and put them on somebody who has perfectly normal hearing or even somebody who has a mild pure-tone hearing loss. But when we start looking at people with more complex hearing needs, they just become frustrated. Fitting the right solution into the complex communication and lifestyle needs of individuals with unique auditory systems and brain experiences really requires knowledge and experience—and that is what we bring. Furthermore, we have to ensure that multiple technologies can be appropriately integrated and that the end-user is capable of implementing the recommended strategy to effectively utilise the recommended system. These often require both provider expertise and individualised training and counselling, which could take a bit of time depending on the digital literacy gap that we may be encountering.

Regarding the type of technology I'm most excited about right now, I tend to stay very focused on patients who have significant hearing difficulties and significantly impacted auditory systems. I am most excited about the potential of new connectivity options using Bluetooth that will allow similar ease of access as we have with telecoils and loop systems. For example, having open-source options, such as the low-energy audio being developed by the European Hearing Industry Manufacturing Associations in collaboration with the Bluetooth Special Interest Group, will allow hearing aid and cochlear implant users to access sound in large venues without requiring complicated pairings or additional technology. It will be very freeing to patients! It will enhance their access to information and entertainment and their enjoyment of media. They can become more engaged with their communities. The concept of finding something that is freely accessible in entertainment venues and large group opportunities is something that I'd be most excited about.

Dr. Zeng: Based on what Angela, Sharon, and Victor just said, we are entering a very exciting time. This naturally leads to the next question: What is your personal and organisational position on the regulatory side? And perhaps, more importantly, as audiologists and as a profession, where and how can you make money as a business?

Dr. Bray: Times of change are times of opportunity. But for some people, these can be times of threat. It is an opportunity for audiology to embrace the challenge even though our initial response might be fear and threat, e.g., “This can't be good for me because it is going to change what I have been doing.” But if we look at the positive side, change can be good. It takes the right mindset to take advantage of an opportunity. Regarding OTC, ADA continues to support the bipartisan and bicameral Over-the-Counter Hearing Aid Act of 2017. We also continue to support the recommendations from the consensus report that came from ADA, AAA, ASHA, and IHS. These are established product requirements: define concise out-of-the-box labeling, define comprehensive inside-the-box labelling, define the new OTC category that is easily comprehensible by consumers, and provide adequate provisions for consumer protection. We continue to support all of those things. Many ADA members may choose to incorporate OTC devices into their practices just as many of them now incorporate PSAP amplifier options. We can also expect to see a continuation of many business practices that incorporate variations of bundling and unbundling of services from the product as determined to be the best for that audiology practice. Decisions about bundling and unbundling are not necessarily dependent upon whether we are talking about hearing devices, hearing accessories, PSAPs, or OTCs because OTCs can be successfully incorporated into a practice with either model.

Dr. Sandridge: Challenges are opportunities. OTCs were initially seen as a huge threat and a huge challenge, but we can take it as an opportunity to incorporate them. As Angela said, it is our responsibility to make sure that we educate the consumers. Noting the findings of the MarkeTrak 10 survey, the people who had gone to health care providers were very determined to go back to and get devices from health care providers because they had the knowledge and expertise. There are many opportunities for us to promote our expertise, knowledge, and abilities as professionals to consumers such that when they have a hearing problem, they may easily want to go get an inexpensive OTC or PSAP, but they know that they can come to us to help them set up their device. We'll be the professionals to help them along the way. For those who will experience distortions, and won't do well with OTCs, for example, we'll be there to help them when they realise these are not their best option.

Dr. Shoup: We at AAA are still in support of the consensus recommendations for the new OTC hearing aid classification. We very much support the idea that the individual member will have to make choices for their unique practices. The Academy does provide multiple resources to assist with planning for the unbundling of services from products.

Most important is to recognise that audiologists are integral to the accurate identification and appropriate management of hearing loss. With their knowledge base, audiologists work to develop a comprehensive treatment recommendation, which may include device selection and optimisation, as well as supportive counselling, training, and guidance through a customised hearing rehabilitation plan on what to expect and how to be successful. OTCs can be part of this process. Some patients may have already accessed OTCs before they see an audiologist. The audiologist can then work with the patient to verify whether the device meets the individual's needs. If it does not, is it possible to optimise that specific device to meet the needs as best as possible? Audiologists must also educate the patient on the appropriate use and care of the device and how to integrate the device functionality into the overall hearing rehabilitation plan.

Also in the discussion of OTC devices, we need to recognise the importance of informed choice. If patients come in with an OTC device that we think may not be best for them, we have the ability to assess it—and I've seen this work beautifully. We need to educate patients about speech sounds—which speech sounds they are getting, which ones they are not, and where the device is falling short in giving them access to those speech sounds. They can make the decision then while also considering other options and price points. We must not push these people away and keep them from getting the appropriate education so that they will address their communication needs more effectively.

Dr. Zeng: I enjoyed listening to your insightful comments. It is indeed an exciting time. Thank you for sharing your time and expertise with us in this virtual roundtabl

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