Exploring Tele-Audiology Innovations with Renée Lefrançois of SHOEBOX

Welcome to this Week in Hearing.

Hi, I’m Bob Traynor,

your host for this episode.

And I’m back with my good friend

Renee Lefrancois,

audiologist at Shoebox Limited.

And the interesting thing that I

have to bring to you today is

that we’re going to discuss a

state of the art tele-audiology

platform that Shoebox is

bringing into the marketplace.

Renee,

thanks so much for being with

us today to discuss this

interesting innovation in

telehealth and or tele

audiology programs.

Thanks for having me, Bob.

I look forward to another

discussion and certainly really

looking forward to helping push

the envelope in terms of

innovative clinical solutions.

Well, before we begin,

for those who didn’t see our

last discussion three

months ago or so,

could you refresh us on your

journey to Shoebox and your

position within the company?

I’d be happy to.

I’m a clinical audiologist

licensed in Ontario, Canada.

I’ve been practicing

for 23 years.

The first 15 years of my career

were spent concentrating on

cochlear implantation,

which was fascinating

and still is,

but certainly really living

and breathing innovation.

When we started in implantation,

we were programming with MS Dos

using F1 and F7.

On the little ones.

That was quite the challenge

in itself. But here we are.

I joined Shoebox in 2014,

so I’ve been with them coming

up on nine years.

I was employee number eight and

the first audiologist

to join the team.

We are now over 100 full

time employees,

and I manage a team of twelve

audiologists in our various

branches of audiology and

audiometry. Wow. Well, tele-

audiology, telehealth,

whichever term you’re

using this week.

But since we’re in audiology

treatment modes here

in this discussion,

it’s a really hot topic,

and particularly for those

clinicians who didn’t get that

much experience with it

during the pandemic.

Can you give us an overview of

what tele audiology is and how

it kind of differs from the

traditional practice of the

profession? Happy to do so.

So teleaudiology telehealth

actually represents a broad

spectrum of different clinical

practice scenarios.

So you can actually be in the

same clinic as a patient,

and if you are not face to

face with that patient,

if for whatever reason.

You are in a different room and

on the phone with them or on a

video meeting that is actually

considered telehealth. Now,

if we go to the other extreme,

obviously you can be on

different continents of your

patient and be meeting with them

via phone or video conference

and that also represents

telehealth or teleaudiology.

Now,

different environments and

clinical scenarios have

different requirements and

different benefits to being able

to provide care remotely.

Top of mind for all clinicians

is of course the clinical

validity, privacy,

confidentiality and

effectiveness of the treatment,

the assessment that is

being provided. Now,

we are not alone in the

healthcare realm in terms of

pushing the envelope there.

And COVID,

despite being obviously an

unfortunate development,

did have some positive side

effects and one of them was to

accelerate the provisioning of

remote services due to not being

able to be in the same space as

patients because at the

time it was not safe.

And so we’re taking some of

those learnings together with

our regulatory bodies and

professional standards

guidelines to open up new

avenues of clinical servicing.

Again,

having retrospectives on those

new offerings is really

important to ensure those three

elements that I mentioned the

clinical validity, privacy,

confidentiality and

effectiveness.

And so we really want to make

sure that that is safe and sound

before moving on to

the next level.

And I believe that that’s where

we’re at right now

as an industry.

So what kind of patients are

the best suited for tele

audiological treatment?

Great question.

As with any new service

or product offering,

we really want to start

with adults.

And because this is a

technological endeavor,

adults who are relatively

comfortable with either tablets

or computers, operating systems,

they don’t by any means

need to be an expert,

but someone who is able to

potentially troubleshoot or

knows where to find

the microphone,

the speakers on their laptop to

be able to facilitate the

appointment. Now,

we know that there are

significant cohorts of people

for whom that might not be

possible. For example,

some of our older adult patients

who did not grow up or work with

technology as we know it today.

And so we’ve found ways to move

forward with providing remote

access and remote services. Is,

but with additional support.

And so I think we’ll be going

into that in a little

more detail.

But essentially to start off

working with adults who are

comfortable with technology is

the right place to start.

What are the benefits then to

patients? I know, yeah,

they don’t have to come

to the clinic or this,

but what kind of benefit

can people obtain?

Which types of patients

are they that benefit

from this the most?

Certainly patients who are at a

far distance from a clinic and

understand the effort and cost

that it takes to travel hours,

5-10 hours to their local clinic

understand that additional

efforts for remote care really

benefits them the most.

And so the motivation for that

group of people is quite high,

not to mention the familiarity.

We know that hearing is

obviously just one small portion

of overall human health.

And so in remote communities

many individuals have had

experience with telehealth

either in video format

or telephone format.

And so that is the group that I

think is the most immediately

motivated to help make

this happen.

And so also there are certain

clinics who have initiated

this as part of care,

but not total care.

So for example,

all of the hearing aid fitting

and evaluation will

be done in person.

But perhaps the annual retests

and hearing aid check ins

can be done remotely.

Is there a type of patient that

this is most beneficial?

For sure.

And I’d like to break that

up into four groups.

One is that people who are just

at a significant distance from

a clinic or a clinician.

Two,

those that are

immunocompromised.

We have people who are oxygen or

who have medical conditions for

whom even just seeing the

clinician would be putting

them at risk.

But certainly having them in

a waiting room with other

individuals would multiply that

factor significantly.

Thirdly are our patients

with mobility issues.

We know that often there is a

ledge to get into a sound booth

that is hard for wheelchair and

other types of mobility

assistants to get over.

And often these patients may

need to have special

transportation to and

from the clinic.

And so those are patients that

would be good candidates as

well for remote care.

And as I mentioned

at the beginning,

a complement to existing

appointment. Appointments,

right.

If the point of the appointment

is really just to confirm that

nothing has changed and just to

check in with the patient,

that’s where having them travel

and come into the clinic when

there’s no suspicion of changes

might be a little

bit of overkill.

So in terms of success stories,

really we’ve had a lot of

success not only with

returning patients,

but even new patients for whom

they’re coming in for a hearing

aid evaluation appointment.

Shoebox right now is offering

all of the tests that

I mentioned earlier,

which feed into right up to the

hearing and noise test

for which we use

several different options.

But that is a key part right now

for hearing evaluations to see

if the individual is struggling

in noise.

And so knowing that you can do

that remotely really helps tie

up that appointment nicely.

So those would be two use cases

that I think are really good for

this type of service delivery

cases which might not be as good

of a fit are those, for example,

patients in ENT clinics who are

surgical candidates often

because they require pretty

extensive masking

as well as visual inspection,

et cetera,

or patients requiring

debridement.

I know you said something about,

yeah,

we’re going to start with adults

and things like that,

but can you use this with

pediatric patients at all?

Yes, you can.

Although that’s good. Yes,

that is good.

And actually speaking back to my

past area of concentration

being cochlear implants,

this was something that we were

really putting a lot of effort

into even in the mid

2000s.

I know that in Canada we have a

very large geographic space.

We had patients that were flying

in from a six hour flight close

to the North Pole and so they

were originally coming down once

a month and we were able,

with telehealth and

teleaudiology,

to be able to reduce that to

once every three months as long

as everything was going well.

But it is really important to

say that there are really three

different models of remote care.

One is that the patient is

pretty much fully independent

and so they can be either in

their home or in a medical

clinic where they are the ones

that are handling the computer

or the iPad for the most part.

The second model is when there

is an assistant present,

so that assistant could either

be in the clinic or that

assistant could travel to the

patient’s home to assist

them with the computer.

Set up any internet connectivity

issues,

ambient noise challenges,

and the.

Third model is when an actual

hearing healthcare professional

is present there with a patient.

So that can be an audiology

assistant,

it can be an auditory

verbal therapist,

it could be an audiologist or a

hearing instrument specialist.

And so for children,

we would really be relying on

the last model that I mentioned

and ensuring that they had the

clinical support that was

appropriate for their

developmental age.

So that’s kind of how the remote

process of hearing

assessments work.

Now,

can you tell us a little more

about some of the specifics

relative to the remote

hearing assessment?

Yes,

one of the key issues that

needs to be measured,

documented and considered is

ambient noise monitoring.

We know that very few people,

if any,

have a soundproof booth in their

home, but thankfully,

in parallel fashion,

we are looking at

exploring this,

and we have been for about

the past five years,

in terms of what can clinically

be done in an accurate way

outside of a sound booth.

And with the ANSI and

ISO standards,

they have clearly outlined what

is considered an acceptable

environment for hearing testing.

Shoebox has incorporated those

values into our product so that

it’s relatively seamless for

whether it be the patient,

the assistant,

or the associate hearing

instrument practitioner.

To be able to ascertain whether

or not the environment

is suitable.

We use an external class two

microphone to take those

measurements on a frequency

octave band basis.

And we found through validation

studies that the clinical data

is very much on par with what

you would see in a sound booth

with a manual test,

with an audiologist. Wow.

That’s something we never

thought would be ever something

that would work.

All of the remote tests and all

of the this and that have always

been, well, you know,

you just can’t get

it quite correct.

And it sounds like you guys have

figured out a system that

will do that. Of course,

technology advances and we’re

able to do some of those

kinds of things.

Can you tell us more about the

specific tests that we can

perform via teleaudiology?

And are there any limitations

and challenges with these

specific assessments that you

guys are going to offer

into the market?

With pleasure. So,

air conduction audiometry.

So whether that be pure tone,

speech reception thresholds

or speech discrimination,

testing is relatively easy

to obtain in most quiet

environments.

And that’s because the ears are

covered. And thankfully,

we working alongside.

our audiometric headset

manufacturers.

We use the Radioear DD450

headset that has the best

attenuation of current

Circumaural audiometric headsets.

Inserts do provide better

Attenuation in the lower

frequencies but of course we

know that inserts require

Otoscopy and a hearing

healthcare professional to do

the insertion and so with the

Circumoaural headphones we’re

opening it up to less risk and

less potential error by

visualizing the patient,

putting the headset on

themselves and doing

a visual check.

Now,

when we proceed into

bone conduction,

things shift and that’s because

typically bone conduction is

done with ears uncovered,

especially unmasked bone.

However,

because the maximum permissible

ambient noise levels,

also known as M panels,

are significantly lower

understandably,

when your ears are uncovered it

is next to impossible to,

especially at 500,

meet the maximum noise level in

a non double walled sound

booth scenario.

So how the team at Shoebox

decided to move forward with

this after quite a few different

trials was we moved back to

forehead placement for

the bone conductor,

and that enabled us to keep the

Circumaural headphones in place,

which basically elevates the M

panels to the same level that

we would be using for air

conduction audiometry. Now,

there are a few caveats there.

It does take more power to reach

the cochleas so the calibration

is different for the bone

conductor whether it’s placed on

the mastoid or placed

on the forehead.

In our product you can actually

have both calibrations and

select based on your use case

which you’re going to use.

Now,

if you are using inserts with

that third model I mentioned

with a hearing healthcare

professional present,

then you can use inserts

and if you use inserts,

then mastoid placement is

completely acceptable and

feasible for most people.

It’s just with the big Circumaural

headsets it’s very hard to

have the bone conductor on the

mastoid without touching

anything.

So of course we needed to take

into account the Occlusion

effect which we know is slightly

different for adults and kids

and so we factored that

into our calculations.

You asked if there are some

tests that can’t be done

remotely. Well, yes, now,

right now our Shoebox products

offer video Otoscopy,

which is something that my team

and I were very skeptical

about.

We remember when we were taught.

Technique for otoscopy,

the risk and self otoscopy just

seemed a little too far fetched.

But what we did do is it was

thanks to the team in France,

the original team that created

the laptop product,

that know we’ve had some

good experience.

Why don’t you try it?

So we took a collection of

seven hearing healthcare

professionals,

a mix of audiologists and

hearing instruments specialists,

half of them internal to

Shoebox, half of them external.

And we tested 100 patients.

And we’re proud to say that

of those 100 patients,

we were able to obtain usable

and clear otoscopy images on

100% of the 100 patients.

Now, wow.

Granted,

sometimes it took 15 seconds and

sometimes it took four minutes,

depending on the complexity

of the ear canal,

the cerumen situation.

But knowing that we can factor

that into the time of the

appointment and having those

images saved for either referral

or future consideration if there

are changes is really a star

element of this product.

Great.

Now,

my guess is that

since a lot of people haven’t

done forehead bone conduction in

quite a long time, I mean,

they may still do it in some

components of the profession,

but the average practitioner

likely hasn’t done forehead bone

conduction in quite a long time.

So that may require a little bit

of extra study on their part as

to how to interpret

all those data.

My guess is also that you guys

will probably provide some

help with that component,

knowing that that’s an issue.

You’re absolutely correct, Bob.

So we actually have several

guides that were written for

clinicians to help just bring

front of mind some of the

considerations when they are

deviating a bit from the typical

clinical testing that we’ve

all been quite used to.

And so you can count on the

Shoebox clinical team to be able

to provide that documentation,

some explanations,

if further explanations are

required in terms of how those

calculations are applied,

as well as how to ensure you’re

appropriately using the right

calibration and being able to

move between one and the other.

That’s an interesting idea. Now,

can you get the same kind

of personal care

with a telediology appointment

as you do with an in person kind

of a situation in the clinic?

I always say. In an ideal world,

every patient would be seen

by a highly trained,

hearing healthcare professional

in a double walled sound booth

with all the time in the world

to do all the tests that would

be relevant to that case.

So

I would be remiss if I would say

that any other service delivery

model would be equivalent

to that. However,

we know that this

is not possible.

And I pride myself on my

connection with patients and

reading patients and adapting my

vocabulary, my speed of speech,

my body language in accordance

to my patient’s comfort level,

linguistic level, et cetera.

I was very concerned going into

this telediology trial of 100

patients that that would be

lacking. And I was thinking,

how am I going to gather the

information that I need to be

the best clinician that I want

to be for that patient?

And I have to give the

developers credit. Now,

there’s a lot going in.

There’s a software division

called UX and UI,

user Experience and

User Interface,

in which a lot of research

is done to say, like,

what size of image on

the screen is best.

Too big can make people feel

watched, too small,

can make it not as accessible

for people with vision issues,

et cetera.

And so what they’ve done is in

the instructional phase or

Otoscopy or case history is just

like you and I are speaking now.

We’re at equal visibility.

It’s as close as can be as to

sitting beside each other.

But when the testing occurs,

we don’t want the audiologists

to be the same size

on the screen.

And so what we do is

we minimize that,

but always having that point of

reference on screen so that you

can see whether or not your

patient is showing signs of

discomfort, signs of confusion.

And we actually did poll our

patients after the 100 tele

audiology sessions to say,

did you feel that you

established a good rapport

with your clinician?

And do you feel that it would

have been much better in person?

Of course,

those results were

somewhat mixed,

but an overwhelming majority

were satisfied with the amount

of personal interaction that

they did have with the

clinician. And as I said,

I need to credit the software

platform to do that because if

we didn’t have those

nice clear images,

we wouldn’t be able

to achieve it.

It’s always interesting to say,

in an ideal world,

you would always want to have

the best of everything for

everybody that walks in the

clinic or would be online

or however,

I think a lot of it is

if the clinicians feel

comfortable interacting online,

then the patients are going to

feel much more comfortable.

Interacting online and how

they interact and so on

can be a real factor.

So have you seen some real

success stories with

this system so far?

Indeed we have.

And so the service provision

that is currently set

up for Shoebox,

sometimes that can include a

laptop or using the

patient’s laptop.

And the series of tests that we

would perform would

be case history,

otoscopy, peer tone, audiometry,

bone conduction, audiometry,

speech testing and then speech

and noise testing.

So those of you who are

listening closely will notice

that there were some things

missing there.

One thing is tympanometry and

tympanometry can be done

remotely with a

tympanomic screener.

However,

that is a separate part.

That is not part of the laptop

system that Shoebox offers.

But we are working with

manufacturers to complement

the laptop with a handheld

tympanometer.

Also reflex testing ipsi

reflexes are relatively easy to

do with a portable tympanometer.

Contra reflex is less so.

So I can’t sit here and

say it’s impossible,

but it’s not something that

we’ve started looking at yet,

but we certainly hope that

others are. And then of course,

hearing aid fitting

and verification.

I would imagine that the hearing

aid companies are working on

providing some of these

services remotely.

But right now Shoebox focuses

mainly on diagnostics.

Well,

and that’s a major factor as

you’re beginning to look at

things and as clinicians and

clinics begin to expand their

market areas from just the city

in which they reside or the

county in which they reside,

to other parts of the world.

And as

the licensure issues become more

minimal rather than in the

forefront in some areas,

we’re going to see more and more

of this type of thing and being

able to do the evaluations as

part of it really brings people

into the clinic.

Now,

I think that there are some

licensing and regulatory issues

that go along with the tele

audiology telehealth programs

and I think the construct is

part of that here in the US.

So how do you guys see that

affecting your system?

Well,

we have seen quite a bit of

progress on that front even

before COVID I’d like

to call out,

I believe the state of Louisiana

was one of the first ones that

had a tele audiology license

designed for people who

were out of state.

Where they went through a

shorter licensing process.

And of course,

the cost was less than it would

be to be practicing in person.

But we’re seeing more and more

states come on board with that.

We also have the compact,

the interstate compact

agreement. That’s what I mean.

Compact. Yeah. Not construct.

Whatever it was,

I knew it was there,

and I’ve heard colleagues like

Amynn Amlani and others that talk

about that relatively often.

So I apologize for the wrong

terminology. There no problem.

Actually, Bob,

not a lot of clinicians

have heard of compact.

Those for whom it’s impactful in

their practice would be

on top of things,

but it’s been in the works now,

I believe,

at least three to four years,

and more and more states are

coming on board. Of course,

there’s different factors to

consider when the requirements

for licensure are different

between states,

but it is moving in the right

direction. And again,

we’re not alone in this medicine

and healthcare.

Just last week online,

there was a televised surgery

that was being done from Europe

to north america remotely.

And so, you know,

we’re all figuring this out

together, but keeping in mind,

of course,

that patient safety and privacy

and efficacy is really

the ultimate goal.

Convenience is not the goal.

And so needing to make sure that

we are comfortable with the

level of care and the perceived

level of care from the patient

as we move to expand these

service delivery models. Yeah.

And of course,

as an audiologist and someone

who’s been in clinics and around

patients and so on,

I’m sure you are very concerned

about privacy issues and data

security and a lot of the things

that are really an ethical

concern for all of us

that are clinicians.

So how is that component or that

face of the remote care working?

Well,

we were able to piggyback on

technology in that front,

seeing as the really significant

jumps in

encryption that we’ve known in

the past ten to 20 years,

we were able to basically cut

and paste that from other use

cases such as banking,

and apply this to healthcare.

So a Shoebox has a portal,

but also in terms of its

methodology for transmitting

video and clinical information,

is encrypted in such a way

that it is deemed to be

top of class.

And there have been no concerns

and no breaches to date.

And I think that we look as.

Well to our healthcare and

medical partners in terms of

lessons learned there and how we

can continue to iterate

and improve upon it.

Although I do have to

be fully honest,

is that it hasn’t been

an issue to date.

I think that was something that

was figured out before we came

on board. Well, Renee,

we kind of got off a little bit

talking about some of the

benefits and then who’s going to

be the most special patient for

this type of a treatment

program.

So what would you recommend

to that seasoned veteran that

went through the pandemic and

saw patients on telehealth or

audiology and those who are

brand new to the concept of

telehealth and teletreatment.

Now,

many AuD programs are now making

students study this

to some degree,

but they still don’t have

much experience with it.

So enlighten us a little bit on

what we can do as seasoned

veterans and brand new

clinicians in telediology.

I’d like to share a bit on my

personal experience here and

that is that I believe that good

clinicians are not prescriptive

in their interactions,

but are receptive to patients

differences,

situations and comfort levels.

Now,

as much as the tests that we’re

doing are very similar in person

as the tests that we’re

doing remotely,

the method of testing and the

method of communication is

inherently different.

And so I would welcome

all clinicians,

whether they be new grads or

experienced clinicians,

to take a moment to just reflect

on their persona in terms of

providing remote care. So,

for example,

reading the clinician,

you don’t have the full body

image that you would

have in a clinic,

but you can read a lot from the

shoulders up and facial

expressions.

Certainly looking for nods and

signs of comprehension,

stopping to allow for questions,

which you might want to do more

often in a remote setting

because you don’t have all of

the same visual cues as you

do in person. And also,

I would say,

follow the lead of the person

that you are in a session with.

There are some individuals that

might be more casual,

some prefer being more formal

because they’re on camera.

And I think matching them in

terms of that level of

communication is really helpful

and naturally makes

them feel at ease.

So this is something that I

think all audiologists excel

at in different ways.

And so I basically recommend

going back to your roots and

thinking how am I going to build

my ability to read my patients

and to provide the best care

in this different medium?

And I think you’ll be pleasantly

surprised at some of the tips

and tricks that you’ll.

Pick up quickly as you start

to offer remote care.

We all know patients that

even in the clinic,

when you sit down with them

and you say, well,

you usually work with people who

are having some hearing loss.

And some will sit there and they

will actually talk to you

forever just on that stimulus.

And others will sit there

and say, yes.

And then what do you do?

So I would encourage our

colleagues as they not only work

with telehealth and

tele audiology,

but also in their face to face

interactions with patients to

consider personal style.

I did an article a year or two

ago for Hearing Review

on personal style,

because there’s four major

personal styles,

and if we tune it one to

another to another,

that’s a lot different than just

looking at hearing loss and

age of individuals.

Excellent observation and

recommendation there.

I remember in my market area,

we were in a city,

and some of my patients were

150 miles out east of us.

And they would come in and you’d

spend ten minutes on the Hi,

how are you?

And then you’d spend ten minutes

on the issue at hand,

which could have been anything

from minimal wax to

a zip zip kind of

adjustment,

and then it’s another ten

minutes of a see you later,

and then it’s another 3 hours

for them all the way back home.

So I think all of us have seen

patients like that

over our careers,

and this kind of a system will

be a godsend for those

individuals as well as for those

that you’ve mentioned that do

have some mobility

issues and some

immunocompromises and those

kinds of things.

So thanks so much for being

with us today, Renee.

And today my guest has been

Renee Lefrancois from

shoebox limited.

And

now it appears that there’s a

possibility we can do air

conduction and bone conduction,

speech testing, video otoscopy,

and even speech in noise,

which gives us a tremendous

capability to handle patients.

And again, thanks again, Renee,

for being with us.

Thanks to all you who tuned in

to this episode for being

with us today.

And please join me next time for

another episode of This

Week in Hearing.