By Peter G. Jacobs and Gabrielle H. Saunders
According to a report from the World Health Organization, only 10% of the almost 300 million people worldwide who are estimated to have moderate-to-profound hearing impairment use hearing aids or other assistive technology. The statistics are even worse in developing countries where fewer than 1 in 40 people {{1}}[[1]]World Health Organization, 2012[[1]] with hearing loss have a hearing aid.
Contrast this with a recent report stating that approximately 75% of the world population has access to a cell phone{{2}}[[2]]World Bank, 2012[[2]]. Further, in regions such as Africa, where cell phone usage is growing faster than anywhere else in the world, there are approximately 700 million active cell phones for a population of around 1 billion, and yet hearing health services are virtually non-existent {{3}}[[3]]Swanepoel, Olusanya, and Mars, 2010[[3]].
While many of these phones are not “smart phones,” and thus lack Internet access, they are nonetheless powerful machines. Furthermore, analysts predict that by 2014, smart phones will dominate the mobile market, even in Africa, where the number of smart phones is expected to grow on average 40% a year {{4}}[[4]]GSM Association, 2012[[4]]up to 2017.
AN OPPORTUNITY FOR AUDIOLOGISTS
This stark contrast between the ubiquitous availability of high-tech telecommunication devices and the poor access to hearing healthcare services in the developing world should be seen as an opportunity for audiologists who can use cell phone technology to enable the remote delivery of audiology.
Smart phones have powerful processors that can be used to generate auditory signals; they have sound output ports that are capable of delivering signals to the ears through headphones or loudspeakers; they have high-quality video cameras that can be used for otoscopy; and they have digital output ports (i.e., USB) that may be used to remotely control devices such as audiometers, tympanometers, and hearing aids. Some smart phones have multiple microphones that could be used as adaptive beamformers for hearing aid noise cancellation.
Thanks to healthcare accessibility laws in the U.S. and other countries, smart phones are particularly well suited for interacting directly with hearing aids. Most can stream acoustic data wirelessly via a telecoil or a Bluetooth interface. This capability has spawned a number of hearing-related smart phone applications, including hearing testing apps, hearing loss simulators, apps that shape and amplify sound output, and apps that enable the phone to be used as a visual and tactile alerting device.
However, the most important feature of a smart phone may be its use as a tool for connecting people who are many miles from each other, such as patients who wish to connect with healthcare professionals over a network (i.e., the Internet).
ENVISIONING A SYSTEM OF THE FUTURE
Imagine a teleaudiology system of the future in which a smart phone is used to run software for hearing diagnostics, to fit and adjust a low-cost hearing aid, and to access a web site that not only links audiologists with patients anywhere in the world, but also securely stores patient data such as audiometric records and hearing aid fitting information.
Such a system would require a distribution method for delivering low-cost supplies such as headphones and hearing aids. There would also need to be a way to reimburse the health care providers. The combination of smart phone technology and sophisticated networked apps could enable audiology to be performed in a minimally equipped remote clinic, as follows:
Licensed audiologists in the U.S. would train technicians located in remote communities to carry out standard diagnostic and hearing fitting procedures using interactive video conferencing software. These technicians would work part-time in the community medical clinic.
When someone at the clinic reported hearing difficulties, the technician would use a smart phone app to test the person’s hearing and to make a video recording of the otoscopic exam. These data would be sent over the phone directly to the U.S.-based audiologist, who would determine what intervention was needed. If warranted, a low-cost hearing aid, {{5}}[[5]]Convery et al., 2011[[5]] perhaps in the form of a kit similar to that described by Convery et al. (2011), would be fitted and adjusted by the technician via a USB interface with the technician’s cell phone. The patient would then be instructed by the technician on hearing aid use and upkeep.
In addition, an app would be downloaded onto the patient’s phone. It would provide general hearing aid information and could also be used to improve hearing aid performance by enabling advanced multi-microphone adaptive beamforming and other noise-cancellation algorithms. Payment for the service would go primarily to the technician. However, the U.S.-based audiologists would receive compensation for training technicians and for their participation, or alternatively they could receive a charity tax deduction for their time.
Much of the infrastructure for the teleaudiology system described above is already in place. Inexpensive electronic equipment, worldwide Internet coverage, smart phone apps for hearing testing and hearing aid fitting, and web sites that can connect professionals and consumers are all available today.
However, more needs to be done, right now, to make this form of teleaudiology a reality. Steps must be taken to ensure patient privacy as medical records are stored and transmitted remotely. A viable reimbursement strategy must be developed that benefits healthcare providers as well as patients, and a mechanism must be devised to ensure that all technicians are adequately and equivalently trained.
LET’S CONTINUE THE DISCUSSION
We invite readers to continue this discussion at the National Center for Rehabilitative Auditory Research (NCRAR) biennial conference, which will take place September 18-20, 2013, in Portland, Oregon.
The meeting, titled “Beyond the Audiology Clinic: Innovations and Possibilities of Connected Health,” will examine the application of connected health to audiology from a broad range of perspectives, including those of the clinician, patient, and engineering designers, to enhance knowledge and awareness of the ever-increasing possibilities of connected health (telemedicine) in the field of audiology.
More information is available at the NCRAR web site. Online registration, poster submission, and scholarship application forms will be available on the web site in March 2013.
Peter Jacobs
Peter G. Jacobs, PhD, is an Investigator at the National Center for Rehabilitative Auditory Research (NCRAR), Portland VA Medical Center, and an Assistant Professor in the Departments of Biomedical Engineering and Otolaryngology at Oregon Health and Science University in Portland. His research interests fit generally within the categories of ubiquitous computing for delivering home-based health care solutions, hearing science (specifically hearing aid signal processing and use of otoacoustic emissions for hearing diagnostics), and medical device development.
Gabrielle Saunders
Gabrielle Saunders, PhD, is the Associate Director and an Investigator at NCRAR. Her research interests lie in innovative approaches to auditory rehabilitation, including the use of teleaudiology. Dr. Saunders,the Chair of the September 2013 NCRAR conference on teleaudiology, hopes that readers will consider coming to Portland to attend that meeting.
