How Implementing an Online Hearing Screening Tool Can Motivate Patients and Benefit Clinicians

Welcome to This Week in Hearing. Hello, I’m Bob Traynor, your host for this episode. Today. My guest is Vanessa Gautheir from Shoebox. And we’re going to talk about online hearing screening. Welcome, Vanessa, to This Week in Hearing. Hi, Bob. thanks for having me. And thanks for being with us, but you know, this is a pretty controversial topic in many audiology circles. We’ve been burned many times by things that have been not very accurate on hearing screening online and that type of thing. And I know you’re going to tell us all about how things have changed significantly in this online hearing screening world. Before we do that, though, can you tell me a little bit about your journey, your audiology journey and how you ended up at Shoebox and that type of thing? Of course. So I’ve been an audiologist for almost eight years now, and I used to work in a private clinic. So doing your hearing assessment. Pediatric, adults, fitting hearing aids, rehab. So ya, clinic journey. And then being myself, I was looking for a new challenge. And Shoebox, I was really lucky because I’m based in Ottawa, Ontario, Canada, and their headquarters are also in the same city that I’m in, and they’re looking for an in-house audiologist. So the second audiologist to be hired at Shoebox. So I’ve been at Shoebox now for coming on five years, and I want to say that every year has been so different. And I worked on various projects from occupational health, more testing to hearing screening that we’ll talk about some research as well, tele-audiology and hearing services. So I’ve worked on different things at Shoebox, and it’s really an exciting place to work at. Wow, what a background. and again, thanks for coming to talk to us about this topic. So, can you tell us a little bit about what Shoebox online is? Of course. So it is an online screener. So it’s a self administered hearing screener that obviously can help those that are curious about their hearing. So really is a way to, I want to say, lower the barrier into entry for a personalized hearing health care. So it is a screener that will put an individual that does it into three different categories. So normal hearing, hearing loss or significant hearing loss, and I’ll cover that a bit more later. But it’s really optimized for various devices. So we’re thinking about desktop, laptop or mobile devices as well. So iPad any cell phones. Basically it can be used with also any consumer headphones. So that’s the other big part, is okay, we have the device. Now we need to think about the headphones so it can be used with any headphones. And a lot of research and development has come into play when it comes to those various combination. I also want to state that it’s a test that has been developed for adults only. So we’re only encouraging adults over 18 years old to do the online screener. Okay. so you can use it with telehealth. If you’re doing some telehealth with someone, you could actually use this with them also, it sounds like, correct. So it’s a remote screener where the person is at home, or it could be into, like you said, in a healthcare situation, maybe in a hospital, just a good idea of possible hearing ability. Okay, so now, since we know what the Shoebox online really is, now tell me some things that you can’t do with it. The Shoebox online, it’s not a diagnostic tool. It’s not a medical device. It’s not meant to replace a hearing test or fit hearing aids. It’s really a screener. And at Shoebox, we’re known for various products, so we have a breadth of product offerings from diagnostic to screener. So we do have our Consult audiometer that’s really focused on diagnostic. We have our iPad Pure Test automated platform, and then we have Shoebox online. That’s on the screening side of things. So I feel like we’re covering the whole journey from screener to diagnostic, but today we’re focusing on the screener side of things that is not a medical device, as opposed to our other products. Okay, well, how things have changed in the last number of years? so what really inspired the development of the online screening side of this stuff at Shoebox, and what makes it really different from the other screeners that are out there online? That everyone says, I have this screener on my website, or that please take our online screening. how is the Shoebox online program different from all these other things that are out there? So how it started, it was really our previous CEO whose goal was to create a hearing screener that would be the most accurate in terms of screening ability. And I know accurate is a big word when we talk about screening. That’s why I like to use screen accuracy. because we’re still talking about a screening as opposed to a full comprehensive evaluation. And how it started really started from scratch. It was a couple of days. It was three days inter-departmental kind of brainstorming session. So we had our research and development team developers, product management research team and audiology to ensure that we were really keeping some clinical validity to the test or the screener. So I know that even for me, there was some healthy skepticism coming into this, right, because I’ve done as an audiologist for sure. Yeah, exactly. So I’ve worked in the clinic and I’ve had patients coming in saying I’ve done this test online and I’d always be like, okay so coming into this, I had that background, right, but I think that was helpful to have that, to come into the team with the slight skepticism that was coming from being an audiologist. But it was healthy and it was quickly put aside once we started brainstorming and to see the plan that was forming for the screener. So really what we did, because we know combinations can be so various when it comes to computers. There’s different branded computers, there’s different cell phones, there’s different headphones. So we trialed numerous, numerous, numerous browsers. So even like browsers when it comes to chrome, Safari, mobile devices, computers, consumer headphones. So we trialed all of that and we created offsets for various combination in terms of sound output. So we tried all these different combination and created those offsets a lot of usability, I was just going to say. So this is all to ensure the accuracy of the online screening program. correct. we realized that different headphones, even with, we’re talking about just like, let’s say over the ears headphones, the difference between them being wired to the computer or wireless, had a different sound output coming into play from a computer that could be a mobile device or a computer. So we had to really work with. Various combinations and a lot, a lot of usability testing with normal hearing people and people with hearing loss really defined the final design of the product. At Shoebox We’re really big on accessibility in our design, so you’ll notice that once you go through the test, very accessible as well. And it’s now available in 28 languages. So I think that sets us apart as well when it comes to the wide range of people we can attract. And we did do, if I can jump into that a validation as well. So we have internal validation that we did. And I do recommend for any clinicians out there that are looking into maybe putting a new screening tool on their website or on their clinic’s website to kind of probe into that validation, because it can be really telling. So ours consisted of 98 adults with 196 ears. So we separated the ears and we had individuals with normal hearing, individuals with hearing loss. And we also had a previously obtained audiogram to compare to the screeners results. So each participant was sent a screener and they were not restrained in terms of what they were using. In terms of they could do the test on their laptop, on their phone, they could use their Apple headphones if they wanted to, or just over the ear. Exactly. There was no restrictions whatsoever because that’s what we were validating. And conventional audiometry was used as the gold standard in terms of comparison. But only thresholds at 1000 Hz, 2000Hz and 4000Hz were used to match really the tones that were detected during the screener. So after we did that, we found a screening accuracy of 93%. So 93% of ears were classified correctly into either good hearing or hearing loss. So we only use the two buckets by looking at those threshold from an audiogram to the screener. And 93% of ears were identified correctly. We had a sensitivity rate of 95% and specificity of 91% when we were looking at classification based on threshold based audiometry. So we know there’s challenges when it comes to doing an online screener. Right. We have no control over the environment. Obviously, we’re used to a booth or very controlled environment. Now we don’t know are they living next to a highway where it’s really loud? Is the fridge next to them and it’s running? Or is there an AC? Right. No control over the environment, but that makes it hard, but also no control about the headphones. So we’re dealing with uncalibrated headphones. So that was really helpful to do that validation to build trust for users. Yeah. So now that we know that you have done a lot of work at Shoebox and with the audiology people and the engineers and everybody else that’s involved in the project. but before we get there what was used as good hearing and what was used as bad hearing, We used a threshold of 30 dB. So what we would use in conventional audiometry as mild hearing loss was used for comparison as well. So as soon as a threshold at either one, 2kHz or 4kHz was hitting 30 dB that was considered as someone with hearing loss and above 25 or better would be considered someone in normal hearing. And our classification was able to match that. of course we would not be able to take into account isolated low frequency hearing loss in that situation because that’s not a frequency that is tested in Shoebox, online so we would miss that in that validation if there was that isolated low frequency loss. So, Vanessa, can you tell us a little bit about how accuracy is ensured by this online hearing screening program? Sure. So we really identified in the team four factors that work together well to help with that screening accuracy, because, again, we know that it’s self directed assessment and we’re using consumer headphones. So the first one is the device and transducer compensation. So I already talked about the fact that we analyze various headphones, but we do compensate for no variances in sound output depending on the combination. So that’s one. so the test is a really nice flow. So we’re starting with some demographic information and then we move on to a dynamic questionnaire. So it is a questionnaire that is designed to probe into the participant kind of perception of their own hearing ability. And it’s dynamic. So it’s going to select questions based on the previous answers. So depending on your answer question will be different. So that’s something that’s really useful as well for clinician, because that’s something they can review after the fact when they look at the patient’s results, so their perception of their loss. the third one is we have a patented fest methodology that is within the Shoebox online test. So really helps identify, it’s a dynamic range, but it helps identify each individual’s comfort level while listening to a speech file. And we know that as hearing loss increases, the range between an upper comfortable level and a perceivable level decreases. So the more hearing loss we have, the level of that dynamic range will be smaller. So that’s known as a dynamic range. And it was based on some work that was done at Widex by Frances Kuk, a researcher. And it’s really a relative measurement, and it’s independent from headphone types. So for us, it was really a good way to go about this test because it makes it ideal for an online test where we didn’t have no control over the headphones. So we’re using a relative measure of a distance between one level to another. And our fourth component of the test is the multi frequency tone detection. So we do present warble tones at 1kHz, 2kHz, 4kHz, and 6 kHz to better estimate the participants hearing per frequency. So we decided to keep our focus on speech, communication and sound of everyday life kind of frequency. We decided to forego attempting to test the low frequencies because we know it’s very susceptible to background noise, and we’re in an uncontrolled setting where we have no idea what’s going on. So we’re testing really just a 1kHz to 6kHz and to warble tones and again, to ensure that screening accuracy, because we don’t know where the individual is. We do have some steps at the beginning of the test that will prompt the user to ensure they’re in a quiet environment and to avoid let’s say, using low quality headphones or children’s headphones. So we try to make it better for a better screening accuracy. So these are really the four factors that the tests go through that helps us getting that classification at the end into normal hearing loss or significant hearing loss. Well, sounds like there’s been a lot of thought that’s gone into this whole thing now. that we know that it’s an accurate assessment with a lot of research and development that’s gone into the online hearing screening program. can you talk a little bit about why clinics are implementing these things and putting in their protocols somewhere? screeners like the Shoebox online program. So the why, I think there’s different whys into why a clinic would implement something like Shoebox online. The one that I like is it the most, it’s really for expanding hearing health awareness and promotion. So this is a task that can be done by almost anyone, almost anywhere. Right. So from your comfort of your home, we know that hearing loss can be something that’s very emotional. So sometimes to take that first step into looking into your hearing, doing it at home feels comfortable. So we’re kind of breaking that barrier and allowing the person to do this at home where they feel comfortable and allowing them to take the next step eventually. So it can be as well, an education tool. So the test is highly customizable. So there’s some call to action pages prior to the test, after the test, and where you can, as a clinic, put whatever you want. So if you want to educate patients on the effect of hearing loss on the quality of life, or you want to give education on assisted devices, so that’s something that you can do as a clinic. I see it also as being now looking back as a nice icebreaker for an audiologist. Right. So if you know your patient has done this test online, you’ve been able to review the results. It could be a good way to kind of start a conversation. I seen you’ve done that. I see that now. Let’s move it to the next step. So I said something that is a good conversation starter as well. And how the clinics are implementing it, there’s different ways they can embed the link, not the link, but the Shoebox online test on their website. So it is available to anyone that is navigating through their website. It can also be used as a triaging tool. So we know clinics are really busy. And a hearing test can range from 30 minutes to 90 minutes, depending on the type of hearing loss. If different transducers need to be used extensive masking. So sometimes having that first insight, which again, we’re talking about a screening here, but could help for allotment of time for a test. So if we know that someone from the screener has normal hearing, as opposed to it looks like someone has significant loss, that could help triaging our patients coming in. So that test could be sent, let’s say as a direct link as well. The patient doesn’t have to go to the clinic’s website, they could be sent that test. So all the URLs are specific to a patient, so there is unique identifier. So if I’m a clinic and I want to confirm the appointment, I could send the link at the same time and then get an idea of the hearing ability prior to someone coming in. It can be used as a marketing tool, be it used on social media or print advertising. And like I said, it’s highly customizable for branding, so you can put your own logo, your own colors. So that’s something that is really exciting because it’s software based. And there’s that data management as well, that is done between a test being done. It goes to our Shoebox web portal where audiologists can review results. So everything is automated into our Shoebox web platform. So that then contributes to how you handle the user data that’s put into the system. And can you tell us a little bit about, I assume the results are confidential and HIPAA compliant and all of those kinds of things as well. Can you just tell us a little bit about that confidentiality? Because that’s a concern for clinical people, particularly here for sure. Oh yeah, 100%. That’s a great question and I totally agree. every test that’s done with the screener is automatically pushed to our web portal. And it is a privacy protected cloud data storage system. That’s the goal. It’s used to synchronize and safely store the data that is used with Shoebox products. So our shoebox portal is accessible just with a browser and a computer. And it is HIPAA compliant, and it’s going to back up all the data all the results. So that’s really important for us at shoebox cloud privacy side of things as well. And the patients on their side, on their end, they can decide to email the results directly to themselves. And the results can also be remotely reviewed by a professional through the web portal. So it can be assessed at a later date as well when the patient comes in for a hearing assessment. So, yes, it’s always top of mind when it comes to. And the patient then chooses who they might want to review it somehow within the questionnaires and that type of thing. Exactly. So if the patient, let’s say, does a hearing test on a clinic’s website, so that data will go there and they can decide what kind of demographic information they put in as well. Okay, that sounds very reasonable in terms of rather than, it’s like a lot of online things. What happens is you put some stuff in there, next thing you know, you get emails for the next five years from these people. so it sounds like that’s all pretty well controlled by the Shoebox system. our test is really designed to be customizable by the clinic. So if they want to decide that the demographic makes the name mandatory and the email, they can, or they can leave it totally optional for everything. Right. So we really give the power to the user as well to do that. But in the end the patient has the power to input whatever they want. Super. So I understand you’ve got a pretty good system right now, and things seem to be kind of going along. You’ve got a system that works with virtually any headphones, and a lot of research and development that went into it with the factors that you’ve mentioned so far. So what kind of things do you think might happen in the future with this online hearing screening program? And do you have any enhancements and so on at Shoebox that you’re kind of secretly holding back behind the door there someplace that you can enlighten us about? So the beauty of Shoebox and something that I’m passionate about is that we’re a software based product. So that means that we have the ability to really grab feedback from users, from clinician, all that customer feedback. We’re not a stagnant product. We’re software based. So we’re always listening and we’re always enhancing and changing. So really continuous improvements, I think, is one of our strengths. Recently what we launched everything I’ve talked about. So far is mainly from a situation where the hearing screener is done at home. Right. The patients at home, they decide to do a screener. So we’ve just recently launched an onsite mode, again, listening to feedback from users. So it’s a case where customers were interested in assisting the participant in person into doing the hearing screening using their own tablet or device. So what that means is that the environment is more controlled. So it could be at a clinic, at the front desk, so they could have an online test there using their own computer, using their own iPad, and there’s someone assisting the participant or the patient doing it. So the environment is control. We’re using the same flow. However, we remove some steps that are unnecessary in an in person setting. So let’s say choosing the headphones if we’re always using the same headphones, we don’t have to click that, right. We don’t have to set the volume. So the test will be quicker that way. And we added a restart button as well. So if we’re having a lot of people having interest in doing the test, we can quickly click on the restart button. So we’re keeping the information private. So we’re going back to the beginning of the test and no one sees the previous person data. so we have someone on site that is there to explain results and probably walk the person through next step. So now we’ve seen your results, how about we book an in person appointment for comprehensive testing so we have that ability to talk to the participant in real time. And the headphones is a big one as well because we could be using, even if it’s a screener, we could be using DD 450 or DD 65 right there with the patient. And we know they’re headphones that really offer one of the best attenuation for background noise. So we’re really setting an optimal environment while still having a screener that is self directed. So this is what has just been launched again. We’re always coming up with new stuff. so feel free. I would invite anyone to just go to our website as well. Shoebox.md We do have our shoebox online test right on the main package in the middle. And I would love everyone to just go give it a try because our development team, our PM team, they work really hard on it and they’re still working really hard on know, it’s always. Good to talk to people who were involved in the development of things because you know the variable as a clinician, you know the variables and the problems we all had. And whenever somebody said they took an online test well, that’s no good. You got all these variables of the computer and the headphones and the program and all these other different things, but it sounds like that has been controlled. We are now about almost. Well, we’re about 24 years into the new century, so we should have been able to come up with some things that were a lot better than it was in the past. it sounds like it’s at least worth checking out. And those of you who are looking to put an online screening program into your practice, you may want to at least kind of check this one out, because it sounds like at least Vanessa is telling us so, that it has had all kinds of hard scrutiny in terms of being able to be at least as accurate as is humanly and AI possible these days for giving us some idea of how patients are performing. I certainly want to thank Vanessa for being part of our program today for this episode on online hearing screening. So today my guest has been Vanessa Gauthier-Davidson an audiologist at Shoebox. And hopefully we’ve been able to enlighten people on the development in this area of practice. So thank you for being with us today for this episode of This Week in Hearing.