VOLUME 1 | ISSUE 3 | 2011
for thaT Raise Success Rates
By Lowering High Frequencies
The ric revolution Starkey’s Comprehensive RIC Family
First Impressions Keeping pace with new technology and new methods can be challenging. It is difficult enough to make sure that we are following best practices while adhering to administrative policies and business requirements, as well as keeping our quality of care high. Throw in new ideas and technologies, and clinicians in busy practices may have difficulty staying as up-to-date as theyâ€™d like. Consistent with our goal of bringing innovations to you in a familiar format, this issue of Innovations addresses a wide range of topics that focus on the issues and types of patients often seen in busy practices, and looks at current thinking and applications of technology. Many of us do not provide services directly related to cochlear implants, yet we may care for patients with an off-implant side hearing aid or provide counseling regarding candidacy for cochlear implants. This issueâ€™s Clinical Corner features an example of a young adult benefitting from bimodal stimulation. Thinking about responding to the need for more pediatric audiologists? Alison Grimes, Au.D., pediatric audiologist and head of the Audiology Clinic at UCLA, discusses current licensure and competency issues facing pediatric audiologists today. Wondering about emerging technologies such as frequency lowering and binaural processing? The research and development experts at StarkeyÂŽ have been thinking about these issues for some time and offer evidence-based solutions. Interested in looking at performance indicators to ensure quality of care and productivity standards, all while keeping up and improving your practice? Susan Good, Au.D., shares tips developed in more than 10 years of practice experience. Innovations is published in an effort to provide timely and relevant content to practicing hearing care professionals. We are offering what we think is important, but we would also like to hear from you. Go to Blog.StarkeyInnovations.com and post your questions, comments and suggestions, or, if you prefer, please email me directly at Dennis_VanVliet@Starkey.com.
Dennis Van Vliet, Au.D. Editor, Innovations Senior Director of Professional Relations Starkey Laboratories, Inc.
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Research to Reality
Staff Spotlight: Anil Shankar
Spectral iQ: Audibly Improving Access to High-Frequency Sounds 030
Tools & Resources
Live Real Ear Measurement Best Practices for Use
Technology Review RIC Revolution: Starkey’s Comprehensive RIC Family
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There’s a Starkey App for That! 049
TABLE OF CONTENTS
The Gift of Hearing
Binaural Spatial Mapping Optimizes Real-World Hearing Aid Behavior
What You Need to Know about Noah 4
Insight from Alison M. Grimes, Au.D.
A Simple Path to Self Learning
Real-world Advantages of Bimodal Stimulation
News & Views
Binaural Spatial Mapping Optimizes Real-World Hearing Aid Behavior
Shilpi Banerjee, Ph.D.
For decades, researchers and clinicians have emphasized the importance of bilateral hearing aid fittings in minimizing disruptions to the exquisitely-tuned binaural auditory system. The availability of hearing aids with wireless features has renewed interest in the subject and focused the discussion on signal processing.
This article describes the rationale, design and efficacy of Binaural Spatial Mapping, Starkey’s wireless ear-to-
ear communication protocol. Along the way, it debunks some popular notions about binaural hearing, hearing impairment and listener preferences, arriving at a destination that optimizes real-world hearing aid behavior.
Survey Says …
Satisfaction with hearing aids is at an all-time high of 80 percent (Kochkin, 2010). Nonetheless, problems persist in adverse listening situations such as in restaurants, cars and large groups (Kochkin, 2010). These situations are important to hearing aid wearers and typically involve communication or intentional listening (Wagener, Hansen, & Ludvigsen, 2008).
Binaural hearing is hearing with two ears. This is advantageous — compared to monaural hearing — when differences exist between the signals for the two ears. These advantages are greatest in complex and dynamic listening environments, such as restaurants, cars and large groups (Noble & Gatehouse, 2006).
The notion of multiple environment listening utility, proposed by Kochkin (2007), suggests a direct relationship between the number of satisfactory listening situations and overall satisfaction with hearing aids. It stands to reason, then, that improving performance in problematic listening situations would yield increased satisfaction with hearing aids. Indeed, this is the premise of many advances in hearing aid technology. Binaural Spatial Mapping is no exception.
When located directly in front of or behind a listener, the characteristics of a sound are essentially the same at the left and right ears, and binaural hearing provides no benefit over monaural hearing. Moving the sound to, say, the left side has two effects. First, the sound is louder at the left ear than at the right ear, resulting in an interaural level difference (ILD) that is most prominent at frequencies above ~1000 Hz. And, second, the sound arrives at the left ear before the right ear, resulting in
INNOVATIONS | Volume 1 | Issue 3 | 2011
an interaural timing difference (ITD) that is most prominent below ~1000 Hz. ILDs and ITDs are the primary binaural cues for spatial release from masking, a phenomenon more commonly referred to as the cocktail party effect (Cherry, 1953). Complex listening environments are known to increase difficulty in recognizing speech. Furthermore, greater similarity between speech and any interfering noise increases the confusion. One relatively simple method of alleviating this difficulty is to spatially separate the speech from the noise. In persons with normal hearing, this spatial release from masking produces a 12–16dB improvement in the speech reception threshold in noise (Beutelmann & Brand, 2006). Signal processing in hearing aids tampers with the naturally occurring ILDs and ITDs in many ways. For example, wide dynamic range compression could reduce ILDs by applying less gain where the incoming sound is louder and more gain where the incoming sound is softer. Similar effects can occur with other features when, for example, only one device is in the directional mode or more noise reduction is applied in one device than in the other. Directionality and noise reduction are intended to aid listening in complex environments. As such, it is important to consider how often these features are in agreement — i.e., in the same state — in everyday listening situations. According to Banerjee (2011), independent signal processing in a bilateral pair of hearing aids is in agreement — i.e., in the same state — 75–95 percent of the time. Accordingly, binaural cues are intact a large majority of the time. Is it problematic that binaural cues could be disrupted when signal processing in a bilateral pair of hearing aids is in disagreement (as much as 25 percent of the time)? Beutelmann and Brand (2006) have shown that persons with impaired hearing obtain significantly less benefit from binaural cues compared to persons with normal hearing. Stated differently, the presence of hearing loss diminishes the ability to effectively use binaural cues.
These advantages [of binaural hearing] are greatest in complex and dynamic listening environments, such as restaurants, cars and large groups. Thus, preservation of binaural cues through forced synchronization of signal processing in a bilateral pair of hearing aids may not be the optimal solution. Could it be that asymmetric signal processing is a part of the solution rather than the problem? Consider, for example, a situation where the hearing aid wearer is engaged in a conversation with a child in the back seat en route to soccer practice (Figure 1). Ideally, the hearing aids should maintain audibility of the child’s voice in one ear and minimize any interference from road noise in the other. Asymmetric signal processing — where, for example, one hearing aid remains omnidirectional while the other switches to the directional mode — would appear to be advantageous in this situation.
The Case for Collaborative Signal Processing Traditionally, laboratory-based hearing aid research has been conducted in symmetrical sound fields — for example, where the speech signal of interest is
Figure 1: Hypothetical scenario in the car. Hearing aid wearer in the driver’s seat converses with a child in the back seat. Speech signal is located on the rear right side with noise predominantly on the left.
The first study, by Hornsby and Ricketts (2007) examined the effect of symmetric and asymmetric microphone modes under three listening conditions: 1) speech in front with surrounding noise, 2) speech in front with noise on the left side and 3) speech on the right side with noise on the left side. For speech located in front (conditions 1 and 2), directionality in at least one device yielded improved speech understanding in noise, and directional benefit was greatest when both devices were in the directional mode. Interestingly, noise location had no impact on directional benefit — i.e., bilateral directionality was equally beneficial with noise surrounding the listener or only on the left side. For speech located on the right side, a significant decrease in speech understanding was observed with the right device in the directional mode; the status of the left device did not affect the outcome. The authors concluded that when speech is located to the side, the reduction in speech audibility resulting from directional processing on that side is detrimental to speech understanding. In the second study, Banerjee (2010) demonstrated similar results in subjective preference for directionality based on the location of the speech signal. Figure 2 shows the relative likability — compared to the bilateral omnidirectional (O-O) condition — of various microphone configurations; large, positive values indicate better outcomes. For speech located in front, listeners preferred some directionality (O-D or D-O) over none at all (O-O), and bilateral directionality (D-D) was preferred most of all. When speech was located in the rear right, however, listeners had a significant dislike for
INNOVATIONS | Volume 1 | Issue 3 | 2011
directionality on the right side; the status of the left device did not affect the results. This is interpreted as an aversion to the reduced audibility of speech that occurs behind the directional hearing aid. The scenarios evaluated in both of these studies are similar to the hypothetical (but realistic) one mentioned previously — a hearing aid wearing parent in the driver’s seat engaged in conversation with a child in the back seat of a car (as shown in Figure 1). To evaluate the implications of these findings, let us first consider synchronized processing in systems where both hearing aids are forced into the same mode. If the right device was forced into the directional mode because that was the mode selected by the left device (closer to the noise), audibility of the speech signal would be severely impaired. Although speech audibility would be unaffected if the left device was forced into the omnidirectional mode by the right device (closer to the speech), interference from the noise may require the hearing aid wearer to expend more
Likability for Microphone Condition
located directly in front of the listener and the background noise is diffuse or located directly behind the listener. As noted previously, such a configuration results in identical inputs to the two ears and requires no intervention for ensuring binaural benefit. However, the use of asymmetric test setups in two studies provides insight into the judicious use of collaborative signal processing with wireless capabilities.
Speech Location Front Rear Right
The goal of collaborative signal processing is to optimize the overall outcome based on the information available at each ear. Sometimes, this means that asymmetric signal processing will yield the best outcome. In the car, for example, the right device may remain omnidirectional because the directional mode degrades the signalto-noise ratio (SNR); the left device, finding no SNR advantage in either mode, could favor the directional mode in the interest of maintaining comfort. This asymmetric configuration yields maximum speech audibility with minimum listening effort. This power of collaborative signal processing is harnessed in Binaural Spatial Mapping.
The design of the algorithm is based on two guiding principles: 1) preserve audibility whenever speech is present and 2) maintain comfort if speech is absent and/or overall input levels are high.
Speech, the primary vehicle for communication, is arguably the single most important sound for hearing aid wearers. As such, the significance of preserving it cannot be overstated. Hearing aids must rely on a relatively degraded input — mixed in Design of Binaural Spatial Mapping with noise and reverberation — at the microphone Binaural Spatial Mapping is Starkey’s wireless of the device to determine the presence of speech in ear-to-ear communication protocol. It continuously the environment. When both devices are constantly analyzes the acoustic environment surrounding scanning the environment and sharing information, the hearing aid wearer and applies the appropriate it effectively improves the detection of speech at signal processing strategy the far ear by as much for automatic directionality, as 5dB. The practical and slow- and fast-acting noise implication is that with reduction (Starkey’s InVision Binaural Spatial Mapping, Directionality, AudioScapes speech audibility can be and Voice iQ2, respectively). preserved at SNRs that is Starkey’s wireless ear-to-ear Each provides data important are too poor for a single for the protocol to work well. hearing aid to detect the communication protocol. InVision Directionality is based presence of speech. on clinical performance measures and patientSpeech audibility is preserved in two ways. proven results, and it is designed to perform best in First, InVision Directionality selects the microphone highly complex backgrounds of noise. AudioScapes mode (omnidirectional or directional) that yields the is Starkey’s environmental adaptation system. 2 higher (i.e., better) SNR at each ear. And, second, Finally, Voice iQ is the noise reduction and speech fast-acting Voice iQ2 reduces background noise preservation system, which instantly applies variable without adversely impacting the speech signal (Pisa, noise adaptation in all channels during each pause. Burk, & Galster, 2010). Binaural Spatial Mapping can only be achieved with
Binaural Spatial Mapping
effort in listening (Mackersie & Cones, 2011). Increased listening effort can cause stress, take cognitive resources away from the task of driving and possibly lead to increased fatigue over time. Thus, neither outcome of synchronized signal processing is desirable.
Microphone Mode (L-R)
Figure 2: Likability of various microphone modes for speech located in front or in the rear right. Higher likability reflects greater preference. O-O is the reference mode. Asterisks (*) indicate a statistically significant (p<0.05) difference from the O-O mode. Error bars show the 95% confidence interval. O=omnidirectional, D=directional.
inputs from two hearing aids with wireless features.
Shilpi Banerjee, Ph.D., is a Research Audiologist at Starkey Laboratories, Inc. Her research interests include directionality and noise management in hearing aids, advanced digital signal processing algorithms, loudness perception, hearing aid-related plasticity and computer-aided enhancement of the hearing aid experience. Banerjee holds a bachelor’s degree in audiology and speech pathology from Bombay University. She received a master’s degree in audiology and hearing sciences and a Ph.D. in communication sciences and disorders from Northwestern University.
According to Pearsons, Bennett and Fidell (1977), inputs exceeding ~80dBSPL are typically comprised of noise. However, if a speech signal is detected in such environments, Binaural Spatial Mapping attempts to strike a balance between preserving speech audibility and maintaining loudness comfort. This is achieved through collaborative decision making — i.e., the device with the better SNR preserves speech audibility while the other device maintains comfort. Thus, Binaural Spatial Mapping may intentionally cause the left and right devices of a bilateral pair to be in different signal processing states under such conditions. Identical states in both devices are not automatically forced. Finally, an incidental benefit of Binaural Spatial Mapping is that auditory disturbances arising from signal processing algorithms are reduced. Switching and/or adaptation in independently functioning hearing aids can occur with a noticeable time delay that many hearing aid wearers find distracting. Collaborative decision making causes any switching and/or adaptation to occur in both devices simultaneously, thereby minimizing the distraction caused by this behavior.
Validation Galster and Burk (2011) described a large-scale study of 47 patients at various clinics throughout the United States. The study examined various aspects of IRIS™ Technology in Starkey’s Wi Series™ hearing aids with Binaural Spatial Mapping. IRIS Technology is Starkey’s wireless communication protocol, which uses the 900 MHz band within the Industrial and
INNOVATIONS | Volume 1 | Issue 3 | 2011
The Device-Oriented Subjective Outcome (DOSO) scale (Cox, Alexander, & Xu, 2009), asks respondents to rate: 1) their ability to hear speech cues [speech]; 2) amount of listening effort expended in noisy situations [effort]; 3) pleasantness of amplified sound [pleasant]; 4) quietness of the hearing aids [quiet]; 5) convenience of manipulating the devices; and 6) daily use of hearing aids. The first four subscales are directly (speech cues and listening effort) or indirectly (pleasantness and quietness) related to Binaural Spatial Mapping. As shown in Figure 3, study participants indicated significantly better performance — i.e., higher ratings — with Starkey’s Wi Series hearing aids compared to their own devices on the relevant subscales of the DOSO scale. The Abbreviated Profile of Hearing Aid Benefit (APHAB) (Cox & Alexander, 1995) is a selfassessment inventory where respondents report the amount of problems experienced in: 1) communicating under relatively favorable conditions [EC: ease of communication]; 2) communicating in reverberant rooms [RV]; 3) communicating in noisy environments [BN]; and 4) unpleasantness of environmental sounds [AV: aversiveness]. As shown in Figure 4, compared to their own devices, study participants indicated significantly better performance — i.e., fewer problems — with Starkey’s Wi Series hearing aids in reverberant and noisy listening situations. There was also a non-significant trend toward reduction of problems in favorable conditions with Starkey’s Wi Series.
7 6 5
Scientific Medical Spectrum. It is the only wireless hearing aid system that allows wireless ear-to-ear communication, wireless programming and wireless media streaming without any relay devices. Of particular relevance to the present discussion are patient reports on two standardized questionnaires that target real-world hearing experiences.
4 3 2
Own Devices Starkey Wi Series
Figure 3: Patient ratings on the Device-Oriented Subjective Outcome (DOSO) scale. Higher ratings reflect better outcomes. Error bars show the 95% confidence interval. Asterisks (*) indicate a statistically significant (p<0.05) difference in rating between own devices and Starkey’s Wi Series (with Binaural Spatial Mapping). Speech=speech cues, Effort=listening effort, Pleasant=pleasantness, Quiet=quietness.
Aided Problems (%)
About the Author:
Noise is generally considered undesirable and the hearing aid wearer, like anyone else, wants to listen to it as little as possible. Enhanced speech detection, made possible by Binaural Spatial Mapping, allows a conservative approach to maintaining comfort in the presence of background noise. In other words, inadvertent loss of the speech signal at low SNRs is minimized. If only noise is present in the environment, the hearing aids go into the directional mode and apply noise reduction to maintain comfort.
Own Devices Starkey Wi Series
Figure 4: Patient ratings on the Abbreviated Profile of Hearing Aid Benefit (APHAB). Lower rates of aided problems reflect better outcomes. Error bars show the 95% confidence interval. Asterisks (*) indicate a statistically significant (p<0.05) difference in rating between own devices and Starkey’s Wi Series (with Binaural Spatial Mapping). EC=ease of communication, RV=reverberation, BN=background noise, AV=aversiveness.
J O I N
Acknowledgements The author thanks Matt Burk, Ph.D., Elizabeth Galster, Au.D., Ivo Merks, Ph.D., and Justyn Pisa, Ph.D., for their work in developing and evaluating Binaural Spatial Mapping. Thanks are also due to Sara Burdak, Au.D., Burk and Jason Galster, Ph.D., for helpful suggestions on early versions of this paper.
References Banerjee, S. (2010). Laboratory Evaluation of Directional Preference: Effects of Speech & Noise Location, Stimulus Type & Response Criterion. Paper presented at the International Hearing Aid Research Conference. Banerjee, S. (2011). Hearing aids in the real world: Typical automatic behavior of expansion, directionality and noise management. Journal of the American Academy of Audiology, 22(1), 34-48. Beutelmann, R. & Brand, T. (2006). Prediction of speech intelligibility in spatial noise and reverberation for normal-hearing and hearing-impaired listeners. Journal of the Acoustical Society of America, 120(1), 331-342.
Figure 5: Binaural Spatial Mapping is Starkey’s wireless ear-to-ear communication protocol.
Summary Binaural Spatial Mapping, illustrated in Figure 5, is Starkey’s wireless ear-to-ear communication protocol. It applies the combined speed and power of multiple dual-core platforms to achieve parallel processing benefits. This new protocol queries, analyzes and maps the acoustic space surrounding the hearing aid wearer, applying the appropriate signal processing strategy for InVision Directionality, AudioScapes and Voice iQ2. Binaural Spatial Mapping can only be achieved with inputs from two Wi Series hearing aids. Binaural Spatial Mapping’s collaborative decision making allows speech audibility to be preserved, while simultaneously maintaining loudness comfort. This yields demonstrated, real-world benefits to hearing aid wearers.
Cherry, E.C. (1953). Some experiments on the recognition of speech with one and with two ears. Journal of the Acoustical Society of America, 25, 975-979. Cox, R.M. & Alexander, G.C. (1995). The Abbreviated Profile of Hearing Aid Benefit (APHAB). Ear and Hearing, 16, 176-186. Cox, R.M., Alexander, G.C., & Xu, J. (2009). Development of the DeviceOriented Subjective Outcome Scale (DOSO). Paper presented at the American Auditory Society. Galster, E. & Burk, M. (2011). Wi Series: Optimizing the Wireless Experience. Starkey Laboratories, Inc., Technology Paper.
January 4-7, 2012
Hornsby, B.W.Y. & Ricketts, T.A. (2007). Effects of noise source configuration on directional benefit using symmetric and asymmetric directional hearing aid fittings. Ear and Hearing, 28(2), 177-186.
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Kochkin, S. (2007). Increasing hearing aid adoption through multiple environment listening utility. Hearing Journal, 60(11), 28-31. Kochkin, S. (2010). MarkeTrak VIII: Consumer satisfaction with hearing aids is slowly increasing. Hearing Journal, 63(1), 19-32. Mackersie, C. & Cones, H. (2011). Subjective and psychological indexes of listening effort in a competing-talker task. Journal of the American Academy of Audiology, 22(2), 113-122. Noble, W. & Gatehouse, S. (2006). Effects of bilateral versus unilateral hearing aid fitting on abilities measured by Speech, Spatial and Qualities of Hearing Scale (SSQ). International Journal of Audiology, 45(2), 172-181. Pearsons, K.S., Bennett, R.L., & Fidell, S. (1977). Speech Levels in Various Environments (Report No. EPA-600/1-77-025). Washington, D.C.: United States Environment Protection Agency.
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Pisa, J., Burk, M., & Galster, E. (2010). Evidence-based design of a noisemanagement algorithm. Hearing Journal, 63(4), 42-48.
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Wagener, K.C., Hansen, M., & Ludvigsen, C. (2008). Recording and classification of the acoustic environment of hearing aid users. Journal of the American Academy of Audiology, 19, 348-370.
INNOVATIONS | Volume 1 | Issue 3 | 2011
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STARKEY HEARING ALLIANCE
Alison Grimes, Au.D., Shares Perspective on
IN (Innovations): The audiology clinic at UCLA sees
children from areas far removed from Los Angeles. Why do the parents of these children need to travel such far distances for service?
Audiology Alison M. Grimes, Au.D.
While it can be rewarding in many ways, fitting hearing aids on children is no easy task. Many students come into the profession with a desire to work with children, but soon discover that there are many challenges. Poor reimbursement for diagnostic services and hearing aids is one problem, but many other issues face clinicians. The skill set to effectively deal with children differs from that needed for adults. Certainly, the consequences for a misdiagnosis or problem hearing aid fitting are more severe with children.
INNOVATIONS | Volume 1 | Issue 3 | 2011
Recognizing the need for additional skills, as well as how to identify those clinicians with the skills and willingness to work with children, the American Board of Audiology (ABA) developed a specialty certification program with generous support from individuals and the hearing industry, including $75,000 from Starkey. The first cohort of candidates took the examination in Chicago at the AudiologyNOW! meeting in April 2011. To get an inside look at pediatric audiology at a major university program, Innovations interviewed Alison Grimes, Au.D., former American Academy of Audiology president and pediatric audiologist. Dr. Grimes was on the panel of subject matter experts who developed the specialty certification examination.
AG (Alison Grimes): So many factors: the size
IN: As a career, pediatric audiology is one requiring specific skills. What are the attributes necessary to be a pediatric audiologist?
AG: It helps to like kids! Patience, a sense
of humor, an ability to connect and communicate with parents/caregivers, flexibility in testing approaches (if one toy, one method, one approach doesn’t work, it’s important to think of another that might be successful. In a hurry!). In addition, it is essential that audiologists who see children be knowledgeable regarding pediatric protocols and have (and use appropriately) necessary equipment.
of the state, the insurance coverage of the infant/ family, and the relative paucity of skilled pediatric audiologists with access to necessary equipment, for starters. California has over half a million babies born each year. Geographic distances are such that many of these children live great distances from large medical centers where much of the advanced pediatric audiology (e.g., electrophysiologic testing under sedation/anesthesia) is available. Additionally, What are some of the specific precautions needed approximately half of all infants born in the state for diagnosing and treating children with hearing loss that are covered by state Medicaid we typically don’t worry about with adults? (Medi-Cal), and the authorization and In diagnosing children, reimbursement processes the importance of the “crossare cumbersome check principle” (Jerger & Hayes, and result in poor one method, 1976) and use of an evidencereimbursement. As one approach doesn’t work, based pediatric test battery are a result, there are it’s important to think of paramount. For children too young a limited number of for Visual Reinforcement Audiometry another that might be pediatric audiologists (VRA), behavioral tests (“Behavioral or centers participating successful. In a hurry! Observation Audiometry” (BOA)) in Medi-Cal. In addition, are not adequate/appropriate/specific audiologic testing to and sensitive enough for determining the achieve a diagnosis of presence or absence of hearing loss, even hearing loss (or normal hearing) though use of “BOA” and/or noisemakers in this in babies requires specialized fashion is still common. And the test battery must equipment and knowledge, include pediatric-specific protocols (e.g., use of a and audiologists who do high-frequency probe tone for infant tympanometry/ not routinely see infants acoustic reflex determination). Children under may not have the required the age of three years who are diagnosed with equipment and the necessary permanent hearing loss and are fitted with hearing protocols established. For these reasons, infants aids must have at least one diagnostic evaluation who do not pass their birth hearing screens of their auditory brainstem response (ABR) (JCIH, and/or rescreens typically are seen at larger, 2007), and this typically, unless the child is very often hospital-based magnet centers like UCLA. young, requires sedation/anesthesia.
About the Author: Alison Grimes, Au.D., is Head of the Audiology Clinic at Ronald Reagan-UCLA Medical Center and an Assistant Clinical Professor in Head and Neck Surgery at the David Geffen School of Medicine at UCLA. She directs the Newborn Hearing Screening Program at UCLA and serves as one of the American Academy of Audiology (AAA) representatives to the Joint Committee on Infant Hearing. She is also a past president of AAA. Currently, Grimes chairs the Pediatric Amplification Task Force for the AAA, is a member of the Pediatric Diagnostic Guidelines Task Force, and is a subject matter expert for the American Board of Audiology’s Pediatric Specialty Certification initiative. Grimes has served on the California State Speech Language Pathology and Audiology Licensing Board since 2000.
It is now more
typical for a child with a hearing loss to have a minimal, mild to severe hearing loss than a bilateral profound or severe-to-profound SNHL, as compared with previous decades.
INNOVATIONS | Volume 1 | Issue 3 | 2011
On the treatment side, since infants and children are learning language through a variety of inputs, including auditory as well as possibly sign language, it is imperative that the acoustic speech signal be optimized for the child’s individual hearing loss. Children cannot tell you what they hear, and do not know what they don’t hear, so we cannot rely on comments such as, “I hear that; it’s too loud; it’s not clear,” or “I don’t hear the /f/ and /s/ sounds!” In addition to ensuring audibility, it is equally important to ensure that the output of the hearing aid is sufficient, but not excessive. The only way to accomplish this is by probe microphone measures using individual real-ear-to-coupler corrections with an evidence-based, pediatric-specific audibility/output target. Having done this, it is also necessary to incorporate such pediatricspecific features as pediatric earhooks, tamperresistant battery doors, hearing aid retention devices, frequent earmold remakes, easy access to FM systems, frequency lowering algorithms for appropriate candidates, and flexible fitting algorithms to optimize amplification when the opposite ear uses a cochlear implant. In some cases, the delivery system must be by bone-conduction (e.g., in children with atresia/ear canal stenosis).
IN: How is pediatric audiology different today compared to when you started your career in the mid 1970s?
AG: Well, I’ve gotta say that in 1975, when
I started testing children, the definition of a “child” was a three- to four-year-old, not a three- to fourweek- or month- (or day-!) old! VRA was accomplished using hand puppets. And I remember using the pyschogalvanic skin response (PGSR) (Burk, 1958). Well, not in children, but I know that some people did that! Now, we routinely test infants who are one to two weeks old, and strive to achieve “1-3-6” (screening by one month, diagnosis by three months and amplification/enrollment in Early Intervention by six months). We routinely consider the necessity of using general anesthesia to get an ABR on a five-month-old in order to facilitate diagnosis; we look at implanting
children younger than one year of age; and we consider 18 months to be “old” for a first-time hearing aid fitting. Now, we obtain real-ear-to-coupler (RECD) measures when fitting infants and children and use that information to program digital hearing aids, instead of turning trimpots or ordering a hearing aid with a “slope” (Wow, I DO sound old!).
IN: With cochlear implants (CI) being a routine
treatment for profound hearing loss, are hearing aids becoming obsolete for this population?
AG: Not at all! First off, it is now more typical
for a child with a hearing loss to have a minimal, mild to severe hearing loss (i.e., not a candidate for a CI) than a bilateral profound or severe-to-profound SNHL, as compared with previous decades. So, when you consider that about two to three of every 1,000 well babies (and a much greater proportion for NICU babies) have a hearing loss, and the great majority have less than a profound hearing loss, the need for hearing aids is quite considerable, and growing, not shrinking. Even for children with bilateral severe-to-profound hearing loss, it is typical to require a period of hearing aid use prior to implantation — we don’t want to do surgery if a child is achieving adequate audibility with hearing aids. Additionally, the benefits of bimodal (hearing aid in one ear, CI in the other) and/or EAS (electroacoustic stimulation using a hearing aid and a CI in the same ear) are clearly described in the literature. In Europe, an integrated EAS device exists, and it is only a matter of time until we see this device available in the U.S.
IN: In the context of pediatric
hearing aid fittings, what is your approach to determining candidacy for and implementation of any of the various frequency lowering techniques available today?
AG: This is an area where the development
of algorithms (e.g., frequency compression or transposition) and advocacy of widespread use has leaped ahead of adequate research demonstrating efficacy and benefit (and guidelines for implementation of frequency lowering strategies). While some limited research information is now available, there is not adequate guidance, in my opinion, to help clinicians determine when, at what frequency and using what scheme, to best optimize the amplified signal. Most importantly, there is yet to be made available adequate research to demonstrate improved outcomes in speech and language development. This is a promising technology for children who are not CI candidates but for whom adequate high-frequency amplification using conventional hearing aids is not feasible. However, it remains to be seen whether frequency lowering technologies in hearing aids, or shortinsertion EAS implanted devices will prove to be superior.
IN: What advice would you have for an audiology student today who aspires to have a career as a pediatric audiologist?
AG: You’ll never get rich, but you’ll have a lot of fun!
References Burk, K.W. (1958). Traditional and psychogalvanic skin response audiometry. Journal of Speech, Language, and Hearing Research, 1(3), 275-278. Jerger, J.F. & Hayes, D. (1976). The cross-check principle in pediatric audiology. Archives of Otolaryngology, 102(10), 614-620. Joint Committee on Infant Hearing (2007). Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics, 120, 898-921.
Spectral iQ: Audibly Improving Access to High-Frequency Sounds
Jason A. Galster, Ph.D., Susie Valentine, Ph.D., J. Andrew Dundas, Ph.D., & Kelly Fitz, Ph.D.
High-frequency sounds are some of the most valuable
Research to reality
components of spoken language.
Frequencies above 3,000 Hz contribute approximately 25 percent of the audible speech cues required for recognition of spoken language (ANSI S3.5-1997). The highest frequency speech sound, the fricative /s/, is one of the most common consonant sounds in the English language. The peak energy of /s/ when spoken by a child or female talker will fall between 6,300 and 8,300 Hz (Stelmachowicz, Lewis, Choi, & Hoover, 2007) and ranges in level between 57 and 68dB (Behrens & Blumstein, 1988). For some patients with high-frequency, sloping hearing loss, restoration of audibility for these high‑frequency speech cues may not be possible or desirable with conventional amplification. Restoration of audibility for individuals with severe or profound high-frequency hearing loss is often constrained by limited hearing aid bandwidth, feedback oscillation, and poorly prescribed gains. Even when audibility of high-frequency speech sounds can be restored, some patients with severe-to-profound hearing loss may not benefit from amplification and may reject the amplified
INNOVATIONS | Volume 1 | Issue 3 | 2011
sound quality. Sometimes these outcomes are attributed to non-functioning inner hair cells, or dead regions, within portions of the cochlea. In a dead region, mechanical vibration of the basilar membrane is not transduced appropriately to elicit electrical stimulation of the auditory nerve. For patients with cochlear dead regions, the effective result of listening to amplified speech within those cochlear dead regions has been described as “information overload” (Moore, 2001). This information overload is thought to be perceived as distortion by the hearing impaired patient. The inability to restore audibility of highfrequency speech and possible contraindication for the restoration of high-frequency speech are established conundrums of hearing care. In order to address these challenges, restoration of high-frequency speech audibility has been accomplished by the shifting of high-frequency information into lower frequency regions in which hearing loss is less severe and cochlear integrity is superior. In other words, moving high-frequency speech information to lower frequencies should improve audibility for patients with sloping highfrequency hearing loss. With regard to frequency lowering technology, the outcomes of independent reviews have been mixed. Multiple papers have offered
Restoration of high-frequency speech audibility has been accomplished by the shifting of high-frequency information into lower frequency regions in which hearing loss is less severe and cochlear integrity is superior.
systematic reviews of technology designed to lower frequency. Braida and colleagues, in 1979, reviewed the earliest research on frequency lowering; the reviewed studies spanned the 1950s, 1960s and 1970s. The authors observed that frequency lowering techniques of the mid-century were unsuccessful, citing challenges related to the strategies used for frequency lowering, a lack of training and acclimatization, and finally stating that “substantial lowering tends to create sound patterns that differ sharply from those of normal speech; it is not unrealistic to assume that such lowering can only be successful with an intensive, long-term, and appropriately designed training program” (Braida et al., 1979, p. 109). More recently, Simpson (2009) provided an updated review of research outcomes with various techniques for frequency lowering. Portions of that review focused on modern implementations of frequency lowering. Her literature review showed that clinical outcomes related to frequency lowering have improved as compared to those observed earlier by Braida and colleagues. These modern implementations have shown significant benefits in terms of speech recognition that, while variable in outcome across individuals, support the clinical application of these technologies (Kuk et al., 2009; Glista et al., 2009).
Frequency Lowering Techniques Reviewed and Contrasted In this paper, two existing techniques for frequency lowering will be reviewed and contrasted with a third, new technology for improving audibility of high‑frequency sounds. At the time of this publication, two frequency lowering technologies are available as signal processing features from leading hearing instrument manufacturers. These are linear frequency transposition (LFT), available from Widex as a hearing aid feature labeled “Audibility Extender”; and non‑linear frequency compression (NLFC), available from Phonak as a feature labeled “SoundRecover.” Linear Frequency Transposition shifts high‑ frequency sounds to lower frequencies. The shifted high‑frequency information is overlapped with existing lower frequency information. Specific to the implementation of Widex’s “Audibility Extender,” frequencies up to two octaves above a defined start frequency can be lowered as far as one octave below that start frequency. In this example, the term “linear” refers to the fact that the frequency distribution within the lowered information is unchanged. Figure 1, adapted from Simpson (2009), is an illustration of this process. In this illustration, the numbered
6 Panel A
6 Panel B
Figure 1: In this illustration, the numbered boxes represent hearing aid channels, and the increasing channel numbers represent increasing frequency. Panel A shows conventional hearing aid processing and Panel B shows the transposed high-frequency information and its relationship to the lower frequency information.
Figure 2: Two spectrograms: the first, Panel A, was recorded without LFT and the second, Panel B, was recorded with LFT. Each recording is of the same speech stimulus containing a word-medial and word-final ‘SH’ or /∫/. In this example, the white boxes illustrate differences between the two figures, showing the behavior of this system in transposing high-frequency information to lower frequency regions.
6 Panel A
Figure 3: In this illustration, the numbered boxes represent hearing aid channels; the increasing channel number represents increasing frequency. Panel A shows the conventional hearing aid processing and Panel B shows the compressed information and its relationship to the lower frequency information.
INNOVATIONS | Volume 1 | Issue 3 | 2011
Non-linear frequency compression, a second available method of frequency lowering, approaches the lowering of high-frequency information in a manner that is different from frequency transposition. In this case, high-frequency information is moved to lower frequencies by compressing the energy in high-frequency hearing aid channels into a lower frequency range. The highest frequencies are shifted and compressed to the greatest extent, while lower frequency
Similar to LFT, NLFC limits high-frequency hearing aid output above the highest compressed frequency. Figure 4 shows two spectrograms: the first, Panel A, was recorded without NLFC and the second, Panel B, was recorded with NLFC. Each recording is of the same speech stimulus containing a word-medial and word-final ‘SH’ or /∫/. In this example, the white boxes illustrate differences between the two figures, showing the behavior of this system to compress high‑frequency information into a lower frequency region. The band-limiting effect of NLFC is also visible, as there is no output from the hearing aid above 5,000 Hz.
information is shifted to a progressively lesser extent. In Phonak’s “SoundRecover,” a cutoff frequency is established. Below this frequency the amplified signal is unaltered. Above this cutoff frequency all signals are compressed in the frequency domain. Figure 3, adapted from Simpson (2009), is an illustration of the NLFC process. In this illustration, the numbered boxes represent hearing aid channels; the increasing channel number represents increasing frequency. Panel A shows the conventional hearing aid processing, and Panel B shows the compressed information and its relationship to the lower frequency information. Unlike Frequency Transposition, NLFC will not affect frequencies below the defined cutoff frequency. All highfrequency information, falling above this cutoff frequency, will be compressed into a reduced high‑frequency range. Assuming that the compressive behavior does not fall within the range of important formant frequencies, vowel information and quality will be retained. When optimizing the prescription of frequency lowering technology, decreasing the cutoff frequency to a region that contains formant information may compromise harmonic relationships and, by extrapolation, speech quality.
boxes represent hearing aid channels, and the increasing channel numbers represent increasing frequency; Panel A shows conventional hearing aid processing and Panel B shows the transposed high-frequency information and its relationship to the lower frequency information. This process of transposition maintains relationships among highfrequency speech components that can be useful for speech understanding and quality. The overlap of high- and low-frequency information may result in the masking of low-frequency speech information by the transposed higher frequency information. In an attempt to minimize undesired masking of low‑frequency sounds, LFT will only transpose frequency information when a strong high-frequency input is detected. Although the transposition behavior is transient and based on input to the hearing aid, the bandwidth of the device is permanently reduced even in the absence of active transposition. Figure 2 shows two spectrograms: the first, Panel A, was recorded without LFT and the second, Panel B, was recorded with LFT. Each recording is of the same speech stimulus containing a word-medial and word-final ‘SH’ or /∫/. In this example, the white boxes illustrate differences between the two figures, showing the behavior of this system in transposing high‑frequency information to lower frequency regions. The band‑limiting effect of LFT is also visible as the high-frequency energy rolls off quickly above 4,000 Hz.
Figure 4: Two spectrograms: the first, Panel A, was recorded without NLFC and the second, Panel B, was recorded with NLFC. Each recording is of the same speech stimulus containing a word-medial and word-final ‘SH’ or /∫/. In this example, the white boxes illustrate differences between the two figures, showing the behavior of this system to compress high-frequency information into a lower frequency region.
When optimizing the prescription of frequency lowering technology, decreasing cutoff frequency to a region that contains formant information may compromise harmonic relationships and, by extrapolation, speech quality.
6 Panel A
6 Panel B
6 Panel C
Figure 5: The behavior of Spectral iQ: Panel A shows the unaffected hearing aid response. Panel B shows the identification of highfrequency speech and the newly generated high-frequency speech cue. Panel C illustrates that in the absence of high-frequency speech, Spectral iQ remains inactive.
Figure 6: Two spectrograms: the first, Panel A, was recorded without Spectral iQ and the second, Panel B, was recorded with Spectral iQ. Each recording is of the same speech stimulus containing a word-medial and word-final /∫/. In this example, the white boxes illustrate differences between the two figures, showing the behavior of Spectral iQ to identify a highfrequency speech cue and regenerate that cue at a lower frequency.
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Understanding the advantages and limitations faced by established methods of frequency lowering, research staff at Starkey Laboratories, Inc. developed a new technology designed for the treatment of patients with severe-to-profound highfrequency hearing loss. This innovation, called Spectral iQ, restores audibility for high-frequency speech features, while avoiding the distortion and frequency-limiting behavior of traditional frequency lowering techniques. Spectral iQ uses a technique called Spectral Feature Identification to monitor acoustic input to the hearing aid. Spectral Feature Identification identifies and classifies acoustic features of high-frequency sounds. Once appropriate highfrequency features are detected, Spectral iQ uses a sophisticated processing technique to replicate (or translate) those high‑frequency features at a lower, audible frequency. This unique process goes beyond the simple lowering of acoustic input; new features are created in real time, resulting in the presentation of audible cues while minimizing the distortion that occurs with other technologies. To use an example, speech features such as /s/ or /∫/ have distinct spectral characteristics that allow for accurate identification. A broadband noise will have energy across a wide band of frequencies, while a high-frequency speech or music feature will have peaks of energy in the high frequencies and often lesser energy at lower frequencies. These relationships allow for accurate and instantaneous identification and translation of important high-frequency information. Figure 5 illustrates the behavior of Spectral iQ: Panel A shows the unaffected hearing aid response; Panel B shows the identification of a high-frequency speech component such as /s/ along with the newly generated high-frequency speech cue. Panel C illustrates that when the highfrequency speech features are no longer present, Spectral iQ remains inactive until Spectral Feature
About the Authors:
restores audibility for high-frequency speech features, while avoiding the distortion and frequency-limiting behavior of traditional frequency lowering techniques. Jason Galster, Ph.D., is Manager of
Identification again detects the presence of an appropriate speech cue, prompting the creation of a new lower frequency feature.
Clinical Comparative Research with Starkey
Figure 6 shows two spectrograms: the first, Panel A, was recorded without Spectral iQ and the second, Panel B, was recorded with Spectral iQ. Each recording is of the same speech stimulus containing a word-medial and word-final /∫/. In this example, the white boxes illustrate differences between the two figures, showing the behavior of Spectral iQ to identify a high-frequency speech cue and regenerate that cue at a lower frequency. A visual comparison between Panels A and B will note nominal reduction in available bandwidth.
and backed by supporting evidence. Galster
A comparative look at three technologies designed to improve audibility of high-frequency speech cues shows that in order to provide benefit, all of these technologies must introduce a sound that was not previously heard by the wearer. Thus, some patients may need to acclimatize to the change in sound quality. LFT will temporarily shift high-frequency information, both speech and noise, to lower frequency regions, thereby overlapping sounds within the audible range. NLFC brings high-frequency speech and noise into an audible range, distorting some highfrequency cues while preserving low‑frequency information. In contrast, the dynamic nature of Spectral iQ retains the natural distribution of frequencies and comparatively broadband sound
Laboratories, Inc. He investigates the clinical outcomes of modern hearing aid features while ensuring that product claims are accurate has held a clinical position as a pediatric audiologist and worked as a research audiologist on topics that include digital signal processing, physical room acoustics, and amplification in hearing-impaired pediatric populations. Galster holds bachelor’s and master’s degrees from Purdue University and a Ph.D. from Vanderbilt University.
Susie Valentine, Ph.D., is a Research Audiologist at the Starkey Hearing Research Center. She holds a certificate of clinical competence in audiology from the American Speech-Language-Hearing Association and has worked as a clinical audiologist at the Indiana University Hearing Clinic, where she received her Ph.D. Valentine holds a bachelor’s from Lenoir-Rhyne University and a master’s in audiology from the University of Tennessee.
100 Conventional Processing
90 Percent Correct (%)
quality, while also avoiding the introduction of high-frequency noise that was not present in those lower frequency regions. This is accomplished by providing a complementary, audible cue when high-frequency speech sounds such as /s/ and /∫/ are present.
85 80 75 70 65 60 55 50
Evidence for Clinical Application Twenty participants, each with a mild, steeply sloping to severe or profound, symmetric sensorineural hearing loss participated in a large-scale clinical study. Two of twenty participants were not able to meet the demands of the experimental task and are not included in this discussion. Each participant was asked to complete the S-test (Robinson, Baer, & Moore, 2007), in which they identify the presence or absence of a word-final /s/ (e.g., dog vs. dogs). The words were presented in a sound field at 65dBSPL, with a low level of speechshaped background noise presented at 45dBSPL. Detection of the word-final consonant /s/ is an important English language cue that often identifies possession or plurality. Because this is a detection task (similar to finding a threshold for high-frequency speech) rather than a speech recognition task, scoring is done through a statistical measure of d’ (d-prime). The results presented here have been converted to a clinically
Starkey has introduced Spectral iQ — an innovative approach to improving audibility for high-frequency speech sounds — designed to overcome some drawbacks associated with established frequency lowering techniques. 24
INNOVATIONS | Volume 1 | Issue 3 | 2011
Figure 7: Results of the S-test: blue bars show percent correct identification with conventional processing; red bars show percent correct identification with Spectral iQ.
recognizable measure of percent correct using a method described by Hartmann (1997, p. 543). Figure 7 shows the results of the S-test: blue bars show percent correct identification with conventional processing; red bars show percent correct identification with Spectral iQ. The mean data show a group benefit of 13 percentile points, similar to improvements seen with existing technology (Simpson, 2009). In the current study, 16 of 18 participants benefited from Spectral iQ, showing improvements in high-frequency speech detection by as many as 29 percentile points.
Summary Frequency lowering has been a part of hearing aid technology for more than 50 years. Recent advances in signal processing have improved these technologies and their clinical outcomes. Starkey has introduced Spectral iQ — an innovative approach to improving audibility for high-frequency speech sounds — designed to overcome some drawbacks associated with established frequency lowering techniques. Modern approaches to frequency lowering introduce distortion to the amplified signal through the overlap of high- and low-frequency sound or the disruption of harmonic relationships and increased audibility of high-frequency noise. Spectral iQ uses a unique process of Spectral
Feature Identification to analyze, classify and react to speech and other high-frequency features in real time. When a high-frequency feature is identified, Spectral iQ regenerates that feature at a lower, audible frequency, cueing the listener to the presence of high-frequency speech components such as /s/ or /∫/. Unlike competing techniques that limit high-frequency bandwidth, Spectral iQ allows Starkey hearing aids to maintain a comparatively broadband, undistorted frequency distribution, while simultaneously restoring high-frequency speech audibility for patients who may have previously been considered unaidable.
About the Authors:
J. Andrew (Drew) Dundas, Ph.D., is a Research Audiologist specializing in the development of advanced hearing aid technologies. His current research interests include the development of prescriptive algorithms and the investigation of
Acknowledgements We would like to acknowledge the contributions of Nazanin Nooraei, Au.D., John Ellison, M.S., Zheng Yan, Ph.D., and Brent Edwards, Ph.D., for their work in developing and evaluating Spectral iQ.
the effects of hearing aid processing on music perception. Prior to joining Starkey, Drew worked and studied at Vanderbilt University Medical Center and at the Cleveland Clinic Foundation, where his research included
References ANSI (1997). ANSI S3.5-1997. American National Standard Methods for the calculation of the speech intelligibility index. New York. Behrens, S. & Blumstein, S.E. (1988). On the role of the amplitude of the fricative noise in the perception of place of articulation in voiceless fricatives. Journal of the Acoustical Society of America, 84(3), 861-867.
investigations of vestibular assessment tools, hearing aid outcome measure development, and tests for the detection of cochlear dead regions.
Braida, L.D., Durlach, N.L., Lippmann, R.P., Hicks, B.L., Rabinowitz, W.M., & Reed, C.M. (1979). Hearing aids—a review of past research on linear amplification, amplitude compression, and frequency lowering. ASHA Monographs, 19 (Chapter IV, 87-113). Glista, D., Scollie, S., Bagatto, M., Seewald, R., Parsa, V., & Johnson, A. (2009). Evaluation of nonlinear frequency compression: Clinical outcomes. International Journal of Audiology, 48(9), 632-644. Hartmann, W.M. (1997). Signals, sound, and sensation. Woodbury, NY: American Institute of Physics. Kuk, F., Keenan, D., Korhonen, P., & Lau, C. (2009). Efficacy of linear frequency transposition on consonant identification in quiet and noise. Journal of the American Academy of Audiology, 20, 465-479. Moore, B.C.J. (2001). Dead regions in the cochlea: diagnosis, perceptual consequences, and implications for the fitting of hearing aids. Trends in Amplification, 5(1), 1-34. Robinson, J.D., Baer, T., & Moore, B.C. (2007). Using transposition to improve consonant discrimination and detection for listeners with severe high-frequency hearing loss. International Journal of Audiology, 46, 293-308.
Kelly Fitz, Ph.D., is a Digital Signal Processing Engineer specializing in the design and implementation of audio analysis, processing, and synthesis algorithms. As Senior DSP Research Engineer at Starkey, he conducts research combining hearing science, psychoacoustics, and signal processing to
Simpson, A. (2009). Frequency lowering devices for managing high-frequency hearing loss: A review. Trends in Amplification, 13(2), 87-106.
explore the perceptual consequences of
Stelmachowicz, P.G., Lewis, D.E., Choi, S., & Hoover, B. (2007). Effect of stimulus bandwidth on auditory skills in normal-hearing and hearing impaired children. Ear & Hearing, 28(4), 483-494.
Ph.D. in electrical engineering from the
hearing loss and hearing aids. Fitz has a University of Illinois at Urbana-Champaign.
Real-world Advantages of
By Dennis Van Vliet, Au.D.
Allison, age 18, is heading off to college this fall. She was identified with a severe-to-profound hearing loss at a young age. She has enjoyed prompt and consistent intervention with hearing aids and intensive therapeutic services for speech, language, oral communication and special education throughout her elementary and high school years. With Allison’s hearing loss, cochlear implants have always been a treatment option. The decision to opt for an implant was never easy because she received benefit from her hearing aids. Her academic progress was good, and she was smart and engaging enough to develop a lively social network and enjoy her childhood. Delays in her expressive speech were the continued signal that she could do better. Surgeons at a well-known and highly respected otology center hesitated to recommend an implant because her performance was such that she didn’t meet the strict criteria. The gaps in her communicative skills persisted, and she was eventually implanted with a single left cochlear implant as an early teen. Although both ears looked nearly identical on the graphic audiogram, the left ear was chosen based on subtle test findings indicating she would do better with the implant on that side. She continued to wear her old analog power BTE on the right ear. The implant was set up to receive FM input to augment her performance in school, although Allison continued to prefer listening to music
INNOVATIONS | Volume 1 | Issue 3 | 2011
on the right. As with most implant patients, she continued to receive most of her hearing care from the implant center, and only infrequently returned to see her hearing care professional for routine hearing aid care for the right hearing aid. After years of use and care, her old analog power aid and the backup aid formerly worn on the left ear failed; it was time to make a decision about the right ear. The needs assessment revealed that Allison and her parents recognized that the synergy of the implant on the left ear and hearing aid on the right was a preferable option to the unilateral implant. Thus continuing with the right hearing aid was the desired course of treatment. As with many teens, she had very specific ideas Allison, age 18, about the acceptable size cochlear implant and hearing aid and appearance of her wearer. hearing aid. A bronzecolored Starkey S Series™ iQ receiver-in-canal (RIC) instrument was originally selected. Objective measures, as well as subjective preference, indicated good benefit. Over the next year, she wore the aid with good success. In the spring of this year, she came in for routine hearing aid maintenance, during which she talked about her upcoming high school graduation and planned relocation from California to New York
Bronze RIC 13 with AP receiver.
for college in the fall, and how her listening needs may change. Considering the number of unknown obstacles she would be facing, it seemed prudent to make every effort to provide her with technology with the capabilities to optimize her performance in academic as well as social situations. A Starkey Wi Series™ i110 hearing aid was selected. At the time of the fitting, the original 312 battery case was the only option available and was used for the fitting. The new 13 battery case now available would be the perfect choice today because of improved battery life with the identical performance and features, plus the option of FM through the onboard direct audio input capability. The 70dB gain receiver used on Allison’s previous S Series iQ RIC was coupled with the new hearing aid, and the fitting was optimized to provide appropriate benefit. When the wireless media streaming was demonstrated to Allison and her mother, Allison quickly dismissed her mother’s questions, saying, “Mom, you don’t know anything about technology. I’ll handle this!”
About the Author: Dennis Van Vliet, Au.D., an audiologist with 36 years of experience, has provided clinical services in medical, educational and private practice settings. His professional interests have focused on hearing aids, and his opinions are frequently solicited in U.S. and international publications and lectures. Van Vliet earned a B.S. from the University of California, Irvine, his master’s in speech communication from California State University and an Au.D. from Central Michigan University.
Allison’s case is an example of the real-world advantages of bimodal stimulation. Many patients fit with a unilateral cochlear implant will benefit from the use of a hearing aid in the unimplanted ear. Each product alone provides benefit, but the synergy of the two allows for a richer life involving verbal communication as well as enjoying music and other non-speech inputs.
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Staff Spotlight: Anil SHANKAR What is your background? Education: Ph.D. in computer science from the University of Nevada, Reno. Graduate work focused on HumanComputer Interaction (HCI).
How did you start in the hearing aid industry? When did you start at Starkey?
Anil Shankar, Ph.D. Research Computer Scientist
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I joined the Starkey Hearing Research Center (SHRC) in June 2008 after hearing about the HCI initiative and the work going on at SHRC. My graduate work focused on personalizing user interface behavior to a specific user along with a parallel investigation of usability issues. Starkey’s HCI requirement was similar to what I had worked on in graduate school, so I wanted to be a part of the research group in Berkeley. Hearing science was a completely new area to me; I was fascinated by how the perception of hearing works, the impact of the work done by the research group on the daily lives of the hearing impaired, and the stimulating research environment.
What are your main job duties? I am a Research Computer Scientist. At a high level, I help to bootstrap Starkey’s nascent HCI initiatives. My projects involve the planning, design construction and management of usability and user-centered design studies. I plan and perform user research and usability activities including heuristic evaluations, competitive analysis, usability testing and other testing methods. I enjoy working with cross-functional design and product teams. My role is as a chief user advocate promoting user needs, preferences and behaviors through qualitative and quantitative research and analysis. I regularly
document and present research/usability findings and recommendations to design teams. These findings are presented to a multidisciplinary group of stakeholders, project managers, engineers and designers to refine and transform user needs into usable user interfaces. Overall, my work involves playing with novel HCI approaches related to adaptive user interfaces and interaction techniques (brain-computer interfaces, immersive techniques, adaptable user-experience techniques) of relevance to Starkey.
What is a memorable experience from Starkey? I don’t have one memorable experience. I always feel like I achieved something significant when I witness the usability of Starkey’s software improve gradually by an increased adoption of user-centered design principles. However, I’ll admit that getting my car unstuck from two feet of snow on a Sunday morning in the blizzard of last December in Eden Prairie, and then trudging in wet pants to the Tech Center to finish up a usability report that was due Monday with nearly frozen toes was a memorable experience. However, I was prepared for such an adventure because of my interest in mountaineering.
What is the most interesting and/or exciting part of your job? I get to scout for the most interesting techniques related to human-computer interaction (user interfaces, in particular) and apply the advances that are of relevance to Starkey. Having the opportunity to work with the really smart people at Starkey is the most exciting part of my job. Being aware that my work constantly focuses on ameliorating some of the usability issues faced by end users of Starkey user interfaces makes my work exciting and motivating.
What are some of the challenges you face? My challenges are related to the adoption of mature HCI techniques in the hearing aid industry. In this
industry, focused HCI research is still at the early stages when compared to the companies that solely develop software applications. One main HCI challenge is to prove the benefits (or lack) of existing or new user interface capabilities to end users; these end users are usually internal research staff, our customers, or even the hearing impaired population. To pick up the latest approaches, I actively seek information at seminars/conferences from neighboring HCI research groups at UC-Berkeley, Stanford and Xerox-PARC. The close proximity to the cutting-edge work done by these world-renowned research groups helps me to better address the needs of our end users via carefully designed user studies. Typically, recorded videos of end users using a software tool (or software prototype) to accomplish contextually relevant tasks provides the data for these studies. I also use metrics of user performance (task efficiency, task time, etc.) to gauge the comfort of users with a software tool. I use this two-pronged approach to objectively assess a user interface’s benefits to its end users.
What are some of the most common questions you hear in your daily work? Two main categories: questions related to the usability of Starkey’s user interfaces (say, fitting software) and questions related to user interface interactivity (iPads®, brain-computer interfaces, 3D gesture-based interfaces, so on). My favorite questions are those that relate to proving how easy or difficult it is for our customers to use all the cool software tools that we create with usability data. It is a part of the challenge and the fun associated with doing HCI research.
What do you do for fun outside of work? Being 183 miles from Yosemite, I enjoy rockclimbing and backpacking whenever I can.
Is there anything else you’d like to share? Starkey Research is an ideal mix of an academic lab with an industrial lab; the opportunities to innovate and collaborate are some of the best I’ve experienced and heard about in the HCI field.
ear measurements is the standard for care in audiology. In fact, both the American Academy of Audiology (AAA) and the American SpeechLanguage-Hearing Association (ASHA) have protocols defining the use of real-ear measurement
in fittings. To assist practitioners in offering
best-in-class patient care, Starkey has integrated an Inspire®-driven, Live Real Ear Measurement system inside the hearing aids. The only additional equipment needed is a probe tube (AAA, 2008; AAA, 2011; ASHA, 2011).
What It Does Inspire will “Best Fit” every hearing aid to match target reasonably well in an ear that is anatomically average. In doing so, it takes into account not just the ear size, but also the average depth of the shell or earmold and, as of Inspire 2012, the vent size. Inspire does its best to accurately “guess” how to set the gain. On average, it guesses accurately, but for dependable results with each and every fitting, a real-ear measurement is required. When Live Real Ear is added to the fitting equation, Inspire gets the measurement it needs to correct any error in the initial guess it made.
INNOVATIONS | Volume 1 | Issue 3 | 2011
The Live Real Ear Measurement system drives a sequence of automated steps, which, with proper physical setup, will: • Trigger the hearing aid to generate its own 65dB SPL speech-shaped noise. • Amplify the speech noise using initial Best Fit gain. • Pick up the amplified sound at the open end of a probe tube in the ear canal. • Measure the amplified sound delivered from the ear canal to the hearing aid microphone via the probe tube. What happens next will depend on which Live Real Ear option is selected.
“Measure Only” and “Measure and Match” Options When the “Measure Only” option is selected, the real-ear measurement will be displayed along with the fitting target. No further automated steps will be executed. The user can choose whether or not to make adjustments on the basis of the result being higher or lower than expected. “Measure Only” can be used as a verification option after adjustments to Best Fit have been made. When the “Measure and Match” option is selected, a Best Fit is executed before any measurement is made. Once the measurement is obtained, Inspire compares it against the selected target (eSTAT by default) to determine target match
Measurement-Based Real Ear (dB SPL)
Verification of hearing aid fitting with real-
100 90 80 70 60 50 40 30 20
100 90 80 70 60 50 40 30 20
Figures 1a and 1b: “Measure Only,” shown on the left, is the measurement that results using current gain settings (not necessarily Best Fit), without any automatic gain adjustments. “Measure and Match,” shown on the right, is the measurement that results after the automated sequence of Best Fit, first measurement, error calculation and automatic gain adjustment.
error, and gain is auto-adjusted in each band to correct for any mismatch. A second verification measurement is then obtained and displayed to confirm the match to target. Figure 2 shows target match error after a Best Fit on 20 in-the-ears (ITEs) in 20 different ears. Error is defined as the difference between the Live Real Ear “Measure Only” and the target. In other words, this is the target match error after Best Fit. Note that the average error (solid black line) is close to 0dB, but for any given individual the error can be as large as +10dB. This is the expected range of error that comes with normal variations in the physical dimensions of ears and hearing aids, and which can only be reduced when measurements are used instead of predictions. After “Measure and Match,” error is reduced to less than 2dB (the size of one step of gain adjustment). As of Inspire 2012, Live Real Ear can detect the hearing aid vent size by measuring the amount of low-frequency sound leaking out (Figure 3).
Live Real Ear Measurement re: Target (dB)
By Debra Cowley, Au.D.
Measured Target Match Error for 20 S Series iQ ITEs 30 20 10 0 -10 -20 -30 -40 100
This measurement would be rejected by Live Real Ear as invalid
Figure 2: Live Real Ear Measurement error for 20 different Best Fits. The dark black line is the average error not including the orange outlier, which would automatically be rejected by Live Real Ear as an invalid measurement. Low Frequency Leakage for Various Vent Sizes 20
Best Practices for Use
Measurement-Based Real Ear (dB SPL)
Live Real Ear Measurement
Figure 3: Live Real Ear can detect the vent size and “Measure and Match” will correct it, if necessary, by changing the vent size in the Acoustic Options dialog (new in Inspire 2012). Vent size is estimated from the amount of low-frequency leakage measured. Blog.StarkeyInnovations.com
Image 2: Power BTE Live Real Ear.
Live Real Ear Setup Parts: Real-ear parts (probe tubes and coupler adapters) are style-specific. Custom products require only a probe tube which plugs directly into the microphone port. Standard products require a probe tube and an adapter to connect the probe tube to the hearing aid microphone. Simply request “real-ear accessories” with your hearing aid order and you will receive the appropriate parts. For more information and instruction on real-ear setup, see the Inspire demonstration videos. Probe Tube Placement: The ear canal end of the probe tube is marked with six black lines spaced five millimeters apart. The first line from the ear canal end (five millimeter mark) should be aligned with the ear canal end of the hearing aid shell, earmold or earbud. Of course, once the
Image 3: Custom Live Real Ear.
hearing aid is in the ear, the mark on the ear canal end of the probe tube is no longer visible. Before inserting the hearing aid and with the probe aligned as described above, note the number of probe tube marks still visible on the outside (lateral side) of the hearing aid. Use the outside number of marks as your guide for proper probe tube insertion.
The year was 1997; scientists had cloned Dolly the sheep, and the spacecraft Pathfinder had landed on Mars. In the hearing aid industry,
“Measure and Match” is included in Auto Path unless deselected from the sequence. In the Auto Path implementation, the already-selected default fitting formula targets are used (eSTAT unless changed in Preferences by the user).
digital hearing aids were arriving in the market
The Live Real Ear screen with “Measure and Match,” “Measure Only” and input level options may be accessed via Tools g Real Ear Measure (Integrated/Live) or by clicking on the Live Real Ear icon, available from any frequency response adjustment screen. References American Academy of Audiology. (2008). Guidelines for the Audiologic Management of Adult Hearing Impairment. www.audiology.org (accessed June 17, 2011). American Academy of Audiology. Code of Ethics. www.audiology.org/ resources/documentlibrary/pages/codeofethics.aspx (accessed June 17, 2011). American Speech-Language-Hearing Association. Code of Ethics. www.asha. org/docs/html/ET2003-00166.html (accessed June 17, 2011).
INNOVATIONS | Volume 1 | Issue 3 | 2011
Mary MacRae & Aaron Schroeder, M.A.
Accessing Live Real Ear
Figure 4: Illustration of a probe tube.
Figure 5: Live Real Ear tubing.
Revolution with much-anticipated hype; yet, one other
Starkey’s Comprehensive RIC Family
groundbreaking technology was quietly setting the stage for a future revolution.
The intent of the original receiver-in-canal (RIC) design was to address problems for those losses requiring a high-gain hearing instrument — namely occlusion and feedback. By placing the receiver deep into the bony portion of the ear canal, self-generated, bone-conducted sounds would be reduced, therefore minimizing occlusion. Furthermore, Reiter et al. (1997) surmised that feedback could be eliminated by mechanical separation of the microphone and receiver along with the deep placement of the receiver into the ear canal.
Image 1: RIC Live Real Ear.
About the Authors: Based on the original idea, the first modern RIC hearing instrument was released in the fall of 2003. This hearing instrument used a newly created modular design and consisted of a sound processor, a replaceable receiver assembly and a silicone-based soft tip. Between 2003 and 2008, practitioners and hearing aid manufacturers began to realize the potential benefits of RIC technology. Removing the receiver from the behind-the-ear (BTE) case allowed for aesthetically improved design, and state-of-the-art feedback cancellation expanded the opportunities for open-canal fittings. As RIC devices of all shapes and sizes started flooding the market, a large growth trend in the behindthe-ear market was starting to take shape. In the United States between the early 1990s and 2003, BTE hearing instruments maintained a relatively flat market share (Strom, 2010). With the introduction of the first RIC device in 2003, the market started an upward trend that has now resulted in the sales of standard devices exceeding the sales of custom devices (Figure 1).
RIC options As part of this revolution in hearing aid design, focus groups conducted by Starkey showed that professionals and patients alike were looking for stylish options that were comfortable when fit to the ear — something that could be attained by mimicking the ear’s natural curves in case design. Other in-demand features included user controls, moisture protection, effective feedback cancellation and directionality (Galster, Yanz, & Freeman, 2008).
Over the next couple of years, Starkey’s new products, including Zo– nTM and S SeriesTM, improved on the original design. Enhancements included the addition of a telecoil, the extension of available receiver gains up to 70dB with the Absolute Power custom shell (Figure 3), as well as platform and algorithm enhancements.
In the spring of 2008, Starkey released a sleek and contemporary RIC product with a painted finish, chrome microphone cover and accentmolded user control. This product did more than look good in the hand; clinical and laboratory testing showed that this device outperformed three top competitive devices in both directional microphone performance and added stable gain (Galster, Yanz, & Freeman, 2008).
In January 2011, IRISTM Technology, Starkey’s wireless platform, was added to this proven, award-winning case design. This dramatic hardware upgrade introduced Starkey’s Wi SeriesTM, a platform that remains the first and only wireless hearing aid to provide ear-to-ear signal processing, direct-to-hearing aid wireless programming and far-field wireless streaming without a relay device (Galster & Burk, 2011).
With the addition of HydraShield®, a suite of moisture barriers that protects the outside as well as the inside of the device (Figure 2a and 2b),
Current market research shows that RICs represent approximately 37.8 percent (Strom, 2010) of all BTEs dispensed in the U.S. Moira (2011) mentions that potential hearing aid users expect discreet devices that provide an instant fit and easy replacement. With these findings in mind, it’s no surprise that most RIC products are sold with size 312 or 10A batteries. As an interesting
Figure 2a: Battery from RIC without HydraShield.
negative effects to electroacoustic performance were mitigated and all patient requirements for moisture protection had been met.
Mary MacRae joined the Starkey team in 1995 and currently works in product management with a focus on the receiverin-canal (RIC) and behind-the-ear (BTE) product lines. The majority of her time with the company has been spent with the product management group where she has worked on the development of all models, technology levels and feature sets of hearing aids. MacRae gained valuable customer knowledge and experience through the Starkey Group sales organization. She attended the University of Minnesota college of biological sciences, during which she was a teaching assistant for the Martin Luther King math program.
Aaron Schroeder, M.A., joined Starkey
in 2007. In his current role as Manager
of Hearing Aid Products, he leads a
team involved in the development of
Starkey’s future hearing aids. Prior to
10 0 1990
Figure 1: Market penetration for custom products (green curve) versus standard products (orange curve) from 1991 to 2010. Trends are extrapolated from Hearing Industries Association (HIA) data.
this position, he worked as a Research
Figure 2b: Battery from a RIC with HydraShield.
Audiologist in the Clinical Product Research group. Before joining Starkey he worked in a variety of settings including a private practice, hospital and Figure 3: RIC Absolute Power.
university. He earned his M.A. degree from the University of South Dakota and is continuing his studies as a Ph.D. student through the University of Kansas.
INNOVATIONS | Volume 1 | Issue 3 | 2011
Starkey’s comprehensive RIC family: the
Figure 4: Wi Series and X Series™ RIC 312, Wi Series and X Series RIC 13, and X Series Xino™ RIC 10.
Wi Series and X Series RIC 13, Wi Series and X Series RIC 312, and
counterpoint, Kochkin (2009) notes that battery life had the highest negative rating in a survey of satisfaction. The combination of these observations suggests that a RIC product that offers a size 13 battery while maintaining a discreet form factor is a highly desirable option for prospective hearing aid users.
the X Series Xino RIC 10.
designed to enhance real-time audibility by intelligently identifying high-frequency speech cues, then replicating them in lower frequencies; HydraShield2, adding advanced oleophobic properties to the nano-coating to better protect the hearing aids from earwax and other oily substances; and much more. An overview of the color guide and feature set are provided in Figures 5 and 6 of this article. With this family of RIC products, there is a solution for nearly every patient regardless of their cosmetic needs or hearing loss. Whether a wired or wireless RIC is required, battery life is a concern, or a telecoil or DAI is needed, Starkey’s complete family of RIC products has something for everyone.
The lessons learned from market research, in conjunction with market demand, provided input into the requirements that fed development and clinical validation of Starkey’s comprehensive RIC family: the Wi Series and X Series RIC 13, Wi Series and X Series RIC 312, and the X Series Xino RIC 10 (Figure 4). Each RIC contains Starkey’s leading features including Voice iQ2, the noise reduction and speech preservation system that nearly doubles noise reduction capability while still maintaining speech; Spectral iQ, Starkey’s new frequency lowering technology
Conclusion Today, the advantages envisioned by the original designers of the RIC extend far beyond those listed in the original patent; these advantages have driven market trends over the last eight years and revolutionized the hearing industry. We have seen, whether by design or chance, the impact on the market of an instrument that meets professional and user needs. Starkey has responded to the market with a complete line of evidence-based, fully featured, small, wired and wireless RIC devices that meet both professional and patient expectations.
The year is 2011. The number of Internet users worldwide reaches two billion and scientists have grown a human heart in the laboratory from stem cells. In the hearing aid industry, wireless devices are the latest advancement, but what groundbreaking hearing instrument technology is quietly setting the stage for the next revolution? References
Galster, E. & Burk, M. (2011). Wi Series: Optimizing The Wireless Experience. Starkey Laboratories, Inc., Technology Paper. –n: Excellence Galster, J.A., Yanz, J.L., & Freeman, B.A. (2008). In the Zo and Innovation in Hearing Instrument Design. Starkey Laboratories, Inc., Technology Paper.
Kochkin, S. (2009). MarkeTrak VIII: Consumer satisfaction with hearing aids is slowly increasing. The Hearing Journal, 63(1), 19-32. Kochkin, S. (2009). MarkeTrak VIII: 25-Year Trends in the Hearing Health Market. Hearing Review, 16 (11), 12–31.
Automatic Telecoil/ Automatic Telephone
E2E Feature Sync
110/40, 115/50, 128/60, 130/70
16, 12, 8, 6, 4
110/40, 115/50, 128/60, 130/70
16, 12, 8, 6, 4
110/40, 115/50, 128/60, 130/70
16, 12, 8, 6, 4
Moria, A. (2011). Four Transformative Patient Demands: Convenience, Size, Simplicity, Flexibility. The Hearing Review, 18(4), 36-42.
Reiter et al. (1997). US Patent No. 5,606,621. Washington, D.C.: U.S. Patent and Trademark Office. Strom, K.E. (2010). A Market Update and the Top-20 Trends in Hearing Care, Part 1. Hearing Review, 17(5), 12-24
Battery Door Lock
Figure 6: Standard and Bright Colors offered in the Wi Series and X Series RIC 312, Wi Series and X Series RIC 13, and X Series Xino RIC 10.
Figure 5: Feature sets available on the Wi Series and X Series RIC 312, Wi Series and X Series RIC 13, and X Series Xino RIC 10.
INNOVATIONS | Volume 1 | Issue 3 | 2011
for that! Chris Howes & Justyn Pisa, Au.D.
In the past several years, the proliferation of mobile computing devices (Smartphones, iPods , iPads®, Tablets) has skyrocketed at a staggering
Tools & Resources
pace, resulting in equal numbers of mobile
INNOVATIONS | Volume 1 | Issue 3 | 2011
About the Authors:
Chris Howes joined Starkey in 1998 after spending eight years working at Bethesda Naval Hospital and Walter Reed Army Medical Center. Howes is currently a Senior Software Product Manager focusing on the design and development of mobile software
The overwhelming popularity of mobile computing is also clear to our development teams, in that mobile software applications constitute a change in the way we entertain ourselves, educate ourselves and do business with one another. If mobile computing continues to be the large wave that it appears to be, Starkey intends to remain surfing the top of the wave while looking out over the horizon. As a recognized world leader in the hearing aid industry and with best-in-class fitting software, Starkey is again leading the pack in mobile solutions with the development of a variety of mobile applications for the hearing professional and patient.
applications (“apps”) used for navigating these handheld devices. In fact, more than 300,000 software applications have been built for mobile devices in the last three years, and these apps were downloaded a total of 10 billion times in 2010 alone, with projections exceeding 76 billion downloads by the year 2014 (IDC Forecasts, 2010). The statistics available around mobile computing continue to show dramatic growth, and it’s clear that a shift is taking place when it comes to how we take
Like all new technologies, there will be early adopters who are eager to embrace the latest and greatest technologies, those who avoid new technology for as long as possible, and the followers somewhere in the middle that adopt as the technologies become mainstream. In the past year, Starkey has developed 10 different mobile applications: functional applications, such as a simple user remote control; educational applications that are used to highlight a new product or feature; patient-focused apps that let users perform screenings of their own hearing or find a hearing care professional and/or clinician in their neighborhoods.
applications and telehealth concepts
To capitalize on this emerging technology, Starkey believes it’s important to develop applications that excite the early adopters and intrigue the followers while not alienating the technophobes. To do that, Starkey has implemented a distinct vision and approach to creating mobile applications that fit into one of four categories.
clinical audiologist for a private medical
Justyn Pisa, Au.D., is a Senior Software Product Manager at Starkey. Before joining Starkey in 2005, he was a practice. He has helped develop several products including Live Real Ear, Voice iQ and SoundPoint. Pisa earned his master’s degree from Minot State University and his doctorate from PCO School of Audiology.
advantage of these touch-enabled technologies.
Applications that create product and feature awareness
Applications that improve the hearing aid fitting and adoption process
These tools should be a cohesive embodiment of marketing content aimed at driving patients to the hearing healthcare provider while providing practitioners product specifications at the tip of their finger.
These tools are for diagnostics and fitting, as well as rehabilitation, and can be used locally or in telehealth scenarios.
Sweep™: One of Starkey’s first entries, this mobile application S Series showcases our Sweep Technology, the hearing aid industry’s first integration of touch screen technology into a hearing aid. Sweep allows users to adjust volume and hearing aid memories with a touch or sweep of the finger. The application contains key product feature information and can be used by hearing care professionals and patients for demonstration and learning purposes.
SoundPoint: Most successful hearing aid fittings depend on two key elements: 1) a willing patient and 2) your ability to make appropriate and satisfactory fine-tuning adjustments to accurately meet the patient’s needs. SoundPoint is an interactive and intuitive mobile application that engages your patients in the hearing aid fitting process by allowing them to alter the sound quality of their devices in real time with the touch of a finger. SoundPoint adds an element of fun and helps the patient zero in on a preferred setting for his or her unique hearing loss.
S Series™ iQ: Designed to feature our line of S Series iQ products, specifically highlighting Voice iQ, our noise reduction and speech preservation system, designed to reduce noise while preserving speech. This application includes hearing loss sound demonstrations of Voice iQ along with users’ testimonials and hearing loss education resources.
Wi Series™: This application provides an introduction to the new Wi Series product line of wireless hearing aids, designed to help people hear better in noise and connect directly to a variety of media devices, from televisions and radios to MP3 players and computers. This application provides videos and interactive audio comparisons to engage and educate hearing care professionals and hearing loss sufferers about new methods for hearing in historically difficult situations.
NEW THIS FALL Starkey Pediatrics: The pediatric application is our next mobile application built to assist the professional. It will provide a fun and interactive way for pediatric professionals to discuss hearing loss with parents and children, and review the options that are available in Starkey’s pediatric product line. The pediatric application will highlight our ongoing relationship with Nickelodeon™ and will incorporate fun ways to inform and engage both parent and child through movies, electronic brochures and games.
INNOVATIONS | Volume 1 | Issue 3 | 2011
AMP™: The AMP application is a tool developed specifically for hearing care professionals to fit or modify AMP hearing products. The AMP application uses specific tones to make programming adjustments to the AMP hearing devices. Professionals can select one of three hearing presets as the starting point for the fitting. Each preset is based on a specific audiometric configuration and compression scheme. The AMP application provides the option to control four parameters of the AMP devices in discrete 2dB steps: Low Frequency Gain, High Frequency Gain, Overall Gain and Output. Additional features include the ability to select and play a variety of audio clips from the application to help simulate specific scenarios like conversational speech or music.
T2 On Demand: Similar to the AMP application, T2 On Demand provides the professional with the ability to make changes to any hearing aid that supports the T2 On Demand feature. This application also uses specific tones to make adjustments to the hearing aids and provides the option to control several parameters of the hearing aid in discrete 2dB steps: Low Frequency Gain, High Frequency Gain, Overall Gain, Output, and Occlusion control, in any of the hearing aid memories. Additional features include the ability to select and play a variety of audio clips from the application to help simulate specific scenarios like conversational speech or music.
3. Applications that help patients adjust their hearing aids Mobile applications become accessories by leveraging wireless convergence (connectivity) between the hearing aid(s) and a mobile device.
T2 Remote: Our very first mobile application, T2 Remote, takes advantage of a breakthrough technology from Starkey.
It allows users to control their hearing aids with a simple touch on an iPhone or iPod Touch, adjusting the hearing aid memory or volume to the desired setting.
Applications that reinforce the impact of hearing loss and potential solutions
These applications are designed to provide a guide for the patient journey from hearing loss awareness to a hearing aid purchase. Hearing Loss Simulator: The Hearing Loss Simulator Simulator application allows the user to choose a specific hearing loss configuration and then listen to sounds as though he or she has that particular hearing loss. The Hearing Loss Simulator contains pre-recorded common sounds and also provides the option to let you record your own sounds for playback through the different hearing loss configurations. Colorful graphics are included to show where common sounds and individual speech elements are located for loudness and frequency. This is an excellent educational tool for the professional to involve the patient’s significant other in the counseling process. Hearing Loss
Lifestyle Solutions: The Lifestyle Solutions application provides an opportunity for patients to become active participants in the hearing aid selection process by allowing them to describe their individual hearing lifestyle. The patient’s hearing lifestyle description is used to help select the hearing aid product(s) best suited to his or her needs. Overviews of the product features and functionality, along with descriptions of the available styles, are easy to view and compare.
Sound Check: Sound Check is a hearing screening application that allows anyone to quickly evaluate his or her hearing to determine if it is within normal limits or approaching the range of potential hearing loss. Individual results are displayed in an easyto-understand format, as well as providing more detailed views to show results for specific areas of his or her hearing. Screening results are automatically saved to track changes over time or to discuss further with a qualified hearing professional. Sound Check includes learning materials and links to websites with detailed information on hearing loss and how to get help. An automatic locater feature is included to help the user find and contact a qualified hearing professional nearest to him or her.
Measuring Your Business to Improve Care Susan Good, Au.D.
No matter what our practice type, and no matter what role we play in the practice, if we are in the right profession, we want to provide effective service and meet the needs of those seeking help with their hearing. “Those patients needing our help are increasing in number every day. In 2011, the first wave of the baby boomers crossed the threshold into the, ‘65 years and older,’ category, and these numbers are projected to increase dramatically in the coming decades” (Kochkin, 2005). Additionally, the threshold not only categorizes boomers in the demographic where they are more likely to have a hearing loss, it also may have an impact on their attitude about seeking help for hearing loss.
INNOVATIONS | Volume 1 | Issue 3 | 2011
for news, upgrades and more applications from Starkey!
%HI Adoption 23.8
Hearing loss population will reach 41 million by 2025
Adapted from Hearing Review, 2005.
IDC Forecasts Worldwide Mobile Applications Revenues to Experience More Than 60% Compound Annual Growth Through 2014. (2010). Retrieved April 2011 from IDC Insights: http://www.idc.com/about/ viewpressrelease.jsp?containerId=prUS22617910
are proud to be leading the industry in the development and implementation of these unique tools. Be sure to keep updated on starkey.com or through iTunes at http://itunes.apple.com/us/artist/ starkey-laboratories/id336622271
As a technology company, Starkey strives to provide hearing professionals and hearing aid patients with innovative products that provide value and improve quality of life. Mobile applications are no exception, and we
Practitioners will have both the challenge and the opportunity to inform the general population about the services and products available, and to effectively serve those in need. To date, in spite of research and development yielding hearing aids dramatically more effective year after year, we have not had much of an impact in providing the
Hearing aid adoption rates expressed as a percent of people with admitted hearing loss who own hearing aids
According to Barry Freeman, Ph.D., many of the current professionals serving the hearing impaired population are also nearing retirement. The number leaving the profession will likely exceed new graduates over the next decade, putting a greater burden on the remaining practitioners (Freeman, 2009).
Adapted from Hearing Review, 2009.
appropriate incentive for a greater percentage of potential candidates to obtain hearing aids. Historically, the rate of adoption hovers just under 25 percent of potential candidates acquiring hearing aids (Kochkin, 2009). If we want to provide services to those in need, our challenge is to increase awareness and motivation to seek help and follow our treatment advice in our target population. Another challenge is to effectively serve those we see. This discussion will focus on the challenge of effectively serving our patients.
Improving Care We might feel that we do a pretty good job with our patients, and we don’t have much time to sit around and analyze things because we are so busy seeing and caring for them. Here’s the problem with that line of thinking: there are no specific goals, other than getting through the schedule that day, and no targets for improvement. Why improve? We should all be realistic enough to understand that there is room for improvement in the best of us. Looking at the potential for reaching more individuals in need of our services, it is clear that the profession as a whole must improve just to keep up with the increased demand. At any level — student, employee, or clinic manager/owner — we can look at what we have control over and set goals for improvement. Maybe we would like to document and improve the quality of service. To begin, it should be clear that quality is not achieved by simply doing a good job from day to day, and it is not something that just happens. On the contrary, quality is created by establishing processes that are consistently applied, checked and adapted to suit the needs of your clinical setting AND by communicating clearly with the other stakeholders (patients, colleagues,
INNOVATIONS | Volume 1 | Issue 3 | 2011
Taking the time to analyze the performance of individuals and a practice can lead to better patient care and improve the overall health of your business. supervisors, etc.) about reasonable expectations for patient outcomes, timelines, the practice’s goals and objectives, and your personal needs — to name just a few. In other words, a well-defined and consistent process plus communication equals quality. When quality is achieved, your clinic attains results that spell success.
Getting Started: Gather Information, Benchmark, Set Goals Where do we start? Start small. To get past the point of being overwhelmed, pick a few things that need improvement and can be measured. Follow these simple guidelines:
• If personal, make sure they have value for the individual as well as value for the practice • Consider elements contributing to the basic health of the practice: • Relate to basic practice drivers • Address new and existing patients • Contribute to the long-term vision for the practice Benchmarking: Performance goals may be set with the help of benchmarking data. Benchmarking data are known performance statistics drawn from industry standards or past performance in a successful practice. Because practices differ, benchmarks may or may not be appropriate for direct comparison
Want more ideas? Check with your Starkey Group Representative for additional information on benchmarking.
• Obtain reliable and timely information • Use key measures • Compare performance to benchmark data • Plan for future opportunities and pitfalls • Manage by using the information gathered The information you gather must be related to the goals you set for yourself or your practice. Goals may be focused on a number of different aspects of the clinic management or your personal goals within the practice. Goals should: • Be measurable • Be attainable and realistic
but are a standard by which we can judge our performance and track improvements. Selecting and Setting Goals: If a goal is to see a specific number of additional patients in a day, the goal is measurable. However, the patients seen must also contribute to a larger goal supporting the health of the practice. This could include reducing a patient backlog, increasing practice revenue (and thus the personal income share) or offsetting labor or other overhead costs. To be appropriate and sustainable, the underlying principle of the chosen goal should contribute to the health of the practice or improve the the quality of patient care while preserving the health of the practice.
Establishing Key Performance Indicators: Once goals are established, Key Performance Indicators (KPIs) may be selected to measure progress toward achieving them. Depending on the practice type and area within the practice under evaluation, many different goals and KPIs may be used. The KPI examples discussed in this article are general in nature and may apply to clinicians as well as practice owners. Financial performance indicators need to be used with a frequency that offers a realistic picture and allows reaction or adjustments at appropriate times. Daily reports may be helpful for some management decisions, while reports from longer time periods are more appropriate for judging a practice’s business trends. Managers and practice owners may also want to benchmark and monitor referral sources and marketing effectiveness to ensure that the driving forces of referrals are being sustained. KPIs that relate directly to patient care and personal workload may be of more interest to individual employee clinicians. These could include: • Productivity, which is traditionally defined as the ratio of output to input. Another way to think about it is:
The simplest formula for a clinical setting could be defined as: # of hours of direct patient contact
There are many factors that influence this simple formula: complexity of the facility and procedures, staffing, non-clinical duties,
etc. Additionally, it is setting dependent; for instance, productivity in a hospital setting will be defined differently than in a private practice. However defined, the measure may be used to compare performance within that practice setting. Defining these measures can become particularly important in a practice where some necessary work does not produce revenue, and the contribution of those providing the nonrevenue work needs to be recognized. • Average Selling Price (ASP) relates directly to services and products such as hearing aids. In this example:
Sales revenue from new units = ASP # of hearing instruments sold Depending on how much freedom a practitioner is given on setting prices and offering no-charge items, the ASP may offer an indication of general pricing practices. If pricing is standard within the practice and across providers, it may offer a measure of the technology level typically dispensed by the practitioner. The KPI is useful in budgeting, planning and coaching. • Hearing Aid Fit Rate is used to quantify the number of hearing aid candidates who follow a given practitioner’s treatment recommendations and purchase hearing aids. Typically a given set of criteria is used to identify hearing aid candidates as defined by the practice:
# of patients who purchased hearing aids
# of total candidates
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= Fit rate
Start Small. To get past the point of being overwhelmed, pick a few things
Key Performance Indicator Productivity Average Selling Price
that need improvement and
Fit Rate Binaural Rate
can be measured. Some retail-like settings report an average fit rate of 65 percent when patients who return to purchase within six months of the initial visit are factored in. • Binaural Rate quantifies the percentage of patients who purchase hearing aids for both ears:
# of binaural sets = Binaural rate
Total number of patients fit
MarkeTrak VIII reports the binaural rate as 78 percent in the U.S. market (Kochkin, 2010). • R eturn for Credit (RFC) and Retention Rate (RR). RFC is typically discussed as the percentage of patients that return their hearing instruments within the adjustment period. Retention rate is the inverse relationship. RR is the percentage of patients that keep their hearing aids: 100% – RFC% = RR Manufacturers’ RFC data are typically calculated differently than that of a clinical setting where it may not be uncommon for hearing aids to be exchanged for another style, manufacturer or model. Clinical setting RFC targets that do not count exchanges as returns may be in the range of 10 percent or less.
Formula # of hours of direct patient contact / Hours worked Sales revenue from new units / # of hearing instruments sold # of patients who purchased / # of candidates # of binaural sets / total # of patients fit
100% – Return for credit %
(Revenue - cost of goods sold) / Revenue x 100
• Gross Margin Percentage (GM) is the percentage of the selling price that is profit: (Revenue – cost of goods sold)
Apply It Let’s assume that the clinical staff of a practice decides that the needs of their patients would be better served and the practice would be on better financial footing if they could accomplish three goals:
x 100 = GM
Revenue As clinicians, the only way we can continue to provide services to our patients is to maintain a healthy bottom-line. Without a well-balanced approach to patient care and a profitable practice, our services could not be provided. GM is the starting point for earning an adequate bottom-line profit for a practice. In other words, the first step is to sell products for enough gross margin so that all other expenses can be covered and still leave an adequate remainder of profit. Most practices sell different products and levels of technology, some for more GM, some for less. GM percentage is useful in making business decisions regarding where appropriate retail pricing should be set in order to maintain a profitable practice. For instance, GM can become a guide in selecting products for use with third party contracts that set very specific rules for pricing. Targets will depend on specific products, as well as individual markets and practice types.
1. Improve the hearing aid fit rate 2. Raise the technology level of the hearing aids sold 3. Increase the number of patients that keep their technology after the adjustment period Goals such as these may have come out of an analysis of the practice’s patient outcomes and financial performance that demonstrated a need for improvement. Decisions about specific objectives toward those goals may be made by a management team or individual clinicians, as appropriate, and would be more specific about the amount of change desired. The KPI’s relating to the above goals are: Fit Rate, Average Selling Price and Retention Rate. Performance on these KPIs will be compared to current individual and group performance in the practice, as well as benchmark performance from other sources, such as a similar practice in another area willing to share information or national industry standards.
Susan Good, Au.D., joined Starkey Group in August 2003 and works as an expert in business development for retail, audiology and physician-based dispensing programs. She has extensive clinical, teaching and practice management experience. Prior to her current position, she spent 10 years in clinical practice. Good received her Au.D. from the University of Florida and her master’s from Pennsylvania State University.
Taking the time to analyze the performance of individuals and a practice will lead to better patient care and improve the overall health of your business. This ensures that the practice will thrive and remain available to provide services well into the future.
Tikkun Olam: Repairing the World a Mission at a Time Tulkarem, the Mount of Vineyards, is a city with a population of approximately 60,000 persons located on the West Bank of Israel, in the Palestinian Territories. A city first founded by the Canaanites more than 5,000 years ago, its history dates back to biblical times. The Starkey Hearing Foundation and its Israeli partners contributed to the city’s history by hosting the Israel-Palestine Hearing Mission of Peace in the West Bank. More than 1,000 Palestinian children and adults were fit with hearing devices in May 2011 by teams of audiologists and physicians from the U.S. and Israel. At a function held at the Peres Peace Center in Tel Aviv, Israel’s president, Shimon Peres, told the Starkey Hearing Foundation’s founder
William F. Austin that he hopes that this mission “will promote greater communication, peace, and understanding among the local communities through improved hearing.” This unique and historic mission involved the coordination of medical and security personnel, along with volunteers from Israel, Palestine and the U.S. It was made possible through the collaborative efforts of the Starkey Hearing Foundation, the Chaim Sheba Medical Center in Israel, the American Friends of Sheba Medical Center in New York, and Physicians for Human Rights-Israel. “The Starkey Hearing Foundation Israel-Palestine Hearing Mission of Peace is a humanitarian effort
References Freeman, B. (2009). The Coming Crisis in Audiology. Audiology Today, 21(6): 46-52. Kochkin, S. (2010). MarkeTrak VIII: Consumer satisfaction with hearing aids is slowly increasing. The Hearing Journal, 63(1): 19-32. Kochkin, S. (2009). MarkeTrak VIII: 25-year trends in the hearing health market. Hearing Review, 16(11): 12-31. Kochkin, S. (2005). MarkeTrak VII: Hearing loss population tops 31 million people. Hearing Review, 12(7): 16-29.
Left: Barry Freeman with children that were fit with support from Palestinian security forces. Above: People waiting to be fit.
INNOVATIONS | Volume 1 | Issue 3 | 2011
About the Author:
Once the KPI data are collected and reported, how can these numbers help an individual or a practice thrive? For example, binaural rates in the U.S. are typically around 78 percent. If a practitioner has a consistent binaural rate quite different than 78 percent, the clinical team may want to look at other factors to determine why. It may be that the clinician is so convinced that every appropriate fitting should be binaural that he or she will not recommend hearing aids at all unless the patient will accept two aids. In that event, the binaural rate may be unusually high, but the overall fit rate may be low. With a data-based approach, the overall effect of this bias on the patients and the practice may be discussed with the clinician in an objective manner. In our goal setting example above, binaural rate wasn’t a specific target, but on closer analysis, it affects the fit rate of one clinician. The team may decide that this individual clinician needs a unique set of goals to fine-tune his or her approach to fitting and overall contribution to the improvement of the practice.
Right: The fitting, counseling and interpreter teams.
This mission was in the true spirit of Tikkun Olam, a Hebrew phrase that means ‘repairing the world.’
unlike any hearing mission we have done before anywhere in the world,” said Austin. “In our ongoing desire to deliver the gift of hearing to those in need, we thank our Israeli partners and the Palestinian people for giving us the opportunity to bring about a life-changing event for each of the recipients we were able to help. It is our hope that this work will make possible greater understanding and communication.” Barry Freeman, Ph.D., commented, “This mission was in the true spirit of Tikkun Olam, a Hebrew phrase that means ‘repairing the world.’” Asked how he would envision peace, Freeman noted the need “for a peaceful coexistence and mutual recognition and respect for the rights of all people. If we contributed in even the smallest way to this goal by bringing together parties from Israel and the Palestinian people, then we far exceeded our goal of improving the hearing lives of the more than 1,000 persons we fit with hearing amplification.”
Top: Freeman with interpreters and a family who were fit with hearing aids. Bottom: Scenic view of Tulkarem.
INNOVATIONS | Volume 1 | Issue 3 | 2011
During the mission, experts from the Starkey Hearing Foundation joined with audiologists and physicians from Sheba Medical Center and Tel Aviv University to provide the necessary services. Dr. Minka Hildesheimer, Director of Communication Disorders at Sheba, praised “the camaraderie among the teams that provided translation services and that were fitting and counseling the patients.”
Yael Henkin, Ph.D., a Professor of Communication Disorders at Tel Aviv University, led an advance team of audiologists and physicians from the U.S., Bethlehem and Tel Aviv to ensure that all participants had medical clearance for ear disease, audiograms and earmold impressions prior to the mission. She explained that individuals with medically correctable or treatable hearing problems such as cholesteatomas were referred to Sheba Hospital for medical management and that follow-up for the remaining patients who were fit with amplification will be provided by the audiologists in Bethlehem and Tel Aviv.
What was the significance of the Mission? Did it really make a difference? For the children and families that received hearing aids, the mission certainly made a difference in their lives. Take, for example, sisters Aya Ayman Ahmad Daghmash, 10 years old, and Youmna Ayman Ahmad Daghmash, nine years old. The girls were both diagnosed with hearing loss at the age of five and spent several years in a special boarding school away from their family. In order to transfer to a school nearer to their home, their teachers requested that the parents fit them with hearing aids, which the family could not afford. The Starkey Hearing Foundation was an answer to their prayers. “I must admit I nearly cried to see them receive the hearing aids. This is a present from above for us. We thank everyone who made this dream come true,” said the girls’ father.
During the Starkey Hearing Foundation mission, we have managed to give children the ability to hear for the first time in their lives. And I hope they will also hear our calls and yearning for
true peace between our peoples. said, “The hospital’s vision includes helping our neighbors hear. This is something that we have placed an emphasis on for years. On a personal level, when you take away the politics, I feel that we can certainly maintain a true dialogue and partnership between Israelis and Palestinians. During the Starkey Hearing Foundation mission, we have managed to give children the ability to hear for the first time in their lives. And I hope they will also hear our calls and yearning for true peace between our peoples.”
The participants recognized that success would be measured in terms other than just fitting hearing aids. This was as much — if not more — a mission of peace, perhaps summarized best by Dr. Zeev Rotstein, CEO of Sheba Medical Center, who
What you need to know about James LeBranche
In April 2011, the Hearing Instrument Manufacturers’ Software Association (HIMSA) released Noah 4, the latest version of the Noah System software. HIMSA was founded in 1993 with the objective of developing, marketing and supporting Noah — one standard for integrated hearing care software. In this article, HIMSA Marketing Communications Manager James
New features add more WOW to our wireless lineup
LaBranche addresses the most common questions
We’ve enhanced and expanded our popular Wi Series product line to make it even better: including Spectral iQ, our new, intelligent frequency audibility technology, and a flexible, high-performance Receiver-In-Canal with a 13 battery.
concerning the upgrade to Noah System 4.
IN (Innovations): First, the most frequently asked
question: Why upgrade? According to surveys, a large majority of hearing care professionals are satisfied with NOAH System 3. So why should you upgrade to Noah 4?
JL (James LaBranche): The most important reason
is usability. Noah 4 was designed in conjunction with an interface design specialist with one goal in mind: to make it as easy to use as possible.
Our new X Series lineup delivers everything you want, and then some Get our new features and best innovation in every style or configuration your patients might want — from a custom fit Invisible-InThe-Canal (IIC) to Xino™, our smallest, most discreet RIC ever made.
To see our best for yourself, visit StarkeyPro.com
For example, by clicking on a patient name, you have immediate access to all the important patient data on one screen. The main Noah 4 view includes everything from the latest audiogram and device selection to a full list of sessions and a general comment field. And when you are ready to get to work, all your Noah fitting and measurement modules are listed at the top of screen, one click away.
IN: Are there other improvements?
JL: Noah 4 also contains many new features that have long been requested by Noah users. Here are some of the most important additions: • Noah modules now open in their own windows, allowing you to easily navigate between Noah, your fitting module and your measurement module. • You can decide the order of your Noah modules in the module bar. For example, you may want to move your Starkey module so that it always appears as the first Noah module on your screen. • You can now add attachments, such as graphics or pdf documents, to a patient’s Journal entry. • You can share a common patient database between several offices. • You can search for patients based on their hearing loss. • You can save and print comments and reuse them for other reports.
IN: Is Noah 4 expensive? JL: No. An upgrade from a NOAH System 3
license to Noah 4 is free. Please keep in mind, however, that your Noah distributor may charge a fee to cover their support and distribution costs. If you do not already have a Noah license, a new Noah 4 license should cost about the same as a NOAH 3 1-2 user license.
From digital to wireless, invisible to accessories — if you want the best, if you’re looking for what’s next — it’s here.
About the Author: Communications Manager at HIMSA in Copenhagen, Denmark. He has been with the company since 1998. LaBranche has a bachelor’s degree in English and Philosophy from Bowling Green State University and more than 20 years of experience in communication- and IT-related fields.
One big advantage is that Noah 4 license is a site license. This means that Noah 4 can be used on all of your computers at a single office address/ location without extra cost.
IN: Will I need to upgrade my computer to run Noah System 4?
JL: Probably not. If your PC can run NOAH
System 3 and your Starkey module, it should easily be able to run Noah 4.
IN: Is it difficult to upgrade from NOAH 3? JL: HIMSA has worked hard to ensure that
the upgrade from NOAH 3 to Noah System 4 will be as easy as possible. For example, if you are currently running NOAH System 3.5.2 or later and you are connected to the Internet, the Noah 4 installation can automatically migrate all your NOAH 3 data, settings and modules to Noah 4.
In fact, it can even register your Noah 4 license for you during installation. Please note, however, that once you upgrade to Noah 4, your NOAH System 3 software will no longer be available on your computer.
IN: Should you upgrade now or wait? JL: One important thing to make sure of is
that the NOAH 3 modules you rely on also work
INNOVATIONS | Volume 1 | Issue 3 | 2011
with Noah 4. To see if your modules are Noah 4certified, visit our website at www.himsa.com and choose Products>Noah Modules>Noah 4 certified modules. If your modules are already Noah 4-certified, then there is no need to wait. It’s also worth mentioning that thanks to extensive beta testing, Noah 4 has proven to be very stable from the start. In fact, since Noah 4’s release back in April, we have only found a couple of minor issues, and these have already been corrected in an update (available on our website).
IN: Are there more new features on the way? JL: In the near term, one thing to keep an eye
out for is the new Noah 4-based fitting modules. When available, these Noah modules will start up directly from the desktop, making it even quicker to get started with your fitting session. In the longer term, HIMSA is also working to establish partnerships with EMR suppliers in order to allow better integration with Noah 4. And as always, HIMSA will continue to evolve Noah based on user needs and new technologies. For more information on Noah 4, visit the HIMSA website at www.himsa.com and click on Products> All About Noah 4.
A Simple Path to
Self Learning Lorrie Scheller, Au.D.
Prescriptive fitting formulas are a good starting point for hearing instrument fittings, but many patients still require some degree of fine-tuning before they are satisfied with their devices. A patient typically tries initial settings for a week or two and then returns to the office for adjustments. Clinicians are at a disadvantage because they must make fine-tuning decisions based on patient reports, without the benefit of being in the realworld environments experienced by the patient at the time the adjustments are made. This means that some patients require several fine-tuning sessions before they are happy with their hearing instruments.
Dillon and his colleagues (2006) introduced the concept of a trainable hearing aid that could learn the patient’s preferred hearing instrument settings in real-world environments. Such an instrument could be truly customized for an individual patient’s particular listening environments, involving them more directly in the fitting and removing some of the burden of fine-tuning from the clinician. A recent consumer survey showed customers were more interested in buying instruments that are easy to use with no extra controls or gadgets (Morla, 2011). In developing an instrument that could learn user preferences, Starkey’s goal was to design a simple system that could be used by most instrument wearers. The simplest and most common hearing instrument user control is the volume control. According to a recent survey of U.S. hearing instrument users, nearly 60 percent have a volume control on their instruments, and eight percent have a remote control capable of making volume adjustments (Kochkin, 2010). Starkey’s new Self Learning feature is a volume control (VC) learning system that is easy to use for both the professional and the hearing instrument user. A simple design is desirable because it introduces less complexity for the hearing aid user. Patients can simply change volume as
James LaBranche is the Marketing
New Power On Gain Level
Power On Gain
+ 2dB + 2dB
Figure 1: Example of how Self Learning gradually changes the Power On level.
desired in different listening situations. The Self Learning algorithm operates behind the scenes to optimize volume settings. As the hearing instrument is worn, Self Learning tracks and remembers volume control changes made by the patient. If the same change is made consistently over time, the hearing instrument gradually learns the preferred volume level. For example, Mrs. Jones takes care of her three-yearold grandson while his parents are at work. She turns her hearing instrument up by 6dB every day in order to hear her grandson. Over the course of a few days, her hearing instrument will learn the listening level she prefers and gradually adjust her starting gain to that level so she will no longer need to turn up her volume control. This is illustrated in Figure 1. Use of Self Learning requires no special training or instruction for the patient. The feature works automatically and unobtrusively as the patient makes normal volume control adjustments while wearing the instruments. Volume control changes can be made either with a VC on the instrument or via remote control. Since the learning mechanism is only triggered by persistent changes, infrequent up and down movements of the volume control will have no net effect on learning. The goal of this system is to make the hearing instruments easier for patients to use by reducing the volume adjustments required for optimum sound quality. Over time, the patient will need to make volume control changes 58
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less often as the device learns the patient’s preferred settings, yet the volume control is always available when needed. Research has shown that acceptance of hearing aids is dependent on the user’s ability to hear well in multiple listening environments (Kochkin, 2007). Self Learning is available for each active Memory Environment in the hearing instrument. This allows the wearer to establish independent volume level preferences in different listening environments. The Self Learning feature is easy to find in Starkey’s Inspire® fitting software. The Self Learning screen can be quickly accessed via a Self Learning button on the QuickFit screen. If learning has occurred since the last time the instrument was connected to Inspire, a small green attention icon will appear on the button to alert the professional to check Self Figure 2: Attention icon Learning. Figure 2 showing that Learning has occurred. illustrates these icons. The Data Log option found in Inspire’s left navigation bar also allows the professional to view Self Learning information. As illustrated in Figure 3, the screen shows the amount of applied learning for each active Memory Environment.
Self Learning can be set to either “Off” or “Automatic” on the Self Learning screen. When the feature is set to “Automatic,” learned changes are applied to the instrument and are visible to the clinician the next time the instrument is connected to Inspire. The learned changes can be removed on the Self Learning screen, if desired, returning the Power On gain to the previously programmed level. The ability to remove learned changes is available independently for each Memory Environment. As with any advanced feature, Self Learning may not be appropriate for all patients. It is not recommended for those patients who are unable to hear the indicator tones that signal volume changes because they may have difficulty monitoring those volume changes, causing unintended learning in the instrument. Patients with dexterity issues that make it difficult to initiate volume changes on their instruments can still enjoy the benefits of Self Learning with a SurfLink™ Remote Control. Self Learning is well suited to active patients who are interested in a hearing instrument that adapts to their preferences. Self Learning simplifies the patient experience while bringing the fitting closer to the ultimate goal: a satisfied patient.
About the Author: Lorrie Scheller, Au.D., is a Product Manager at Starkey working on fitting software design and usability. Before joining Starkey in 2010, she gained experience as a clinical audiologist, managed a university cochlear implant program and worked in marketing, product development and software design in the hearing aid industry for many years. Scheller holds a bachelor’s degree in communication disorders from Colorado State University, a master’s in audiology from University of Wisconsin-Stevens Point and her Au.D. from Salus University.
Self Learning is available in the new X Series™ and ™ Wi Series hearing aids.
References Dillon, H., Zakis, J., McDermott, H., Keidser, G., Dreschler, W., & Convery, E. (2006). The trainable hearing aid: What will it do for clients and clinicians? Hearing Journal, 59(4): 30-36. Kochkin, S. (2007). Increasing hearing aid adoption through multiple environmental listening utility. Hearing Journal, 60(11): 28-31. Kochkin, S. (2010). MarkeTrak VIII: Customer satisfaction with hearing aids is slowly increasing. Hearing Journal, 63(1): 19-32. Morla, A. (2011). Four transformative patient demands: Convenience, size, simplicity and flexibility. Hearing Review, 18(4): 36-42.
Figure 3: Self Learning screen in Inspire. Blog.StarkeyInnovations.com
NEWS VIEWS Starkey Hearing Foundation Raises $7.2 Million During Gala
The Starkey Hearing Foundation raised $7.2 million at its annual So the World May Hear gala at the St. Paul RiverCentre in July — the most money raised to date. The 11th annual event also attracted the largest contingent of celebrity supporters since the event began, with notables from the worlds of entertainment,
INNOVATIONS | Volume 1 | Issue 3 | 2011
sports and philanthropy walking the red carpet and celebrating the spirit of giving and understanding through hearing. Due to the event’s successful fundraising efforts, the Starkey Hearing Foundation announced it will fund two return hearing missions to Haiti and Israel. The money raised during the gala will be used entirely to fund the Foundation’s various hearing health and awareness campaigns through the year, including domestic and international hearing missions. The gala attracted a record number of 1,600+ guests, who were treated to performances by Reba, Meat Loaf, Miley Cyrus, John Rich, and Kevin Costner & Modern West. Honorees included President Bill Clinton, Marlee Matlin, Doug Pitt and Randall J. Hogan. Other notable attendees included Whoopi Goldberg, Patricia Arquette, Maria Bello, Jordin Sparks, Larry Fitzgerald, Roy Williams and many more!
President Bill Clinton and William F. Austin at the Starkey Hearing Foundation So The World May Hear gala.
Starkey.com Has New Look Starkey.com, Starkey’s patient-facing website, has been updated to provide easier navigation, a greater focus on testimonials, and interactive tools to help people with hearing loss and those who love them get the help they need. Some of the highlights of the site include: • A revitalized homepage that showcases patient testimonials to bring the experience of wearing Starkey hearing aids to life. • A new structure for researching Starkey products that allows visitors to search by style or technology. • An interactive hearing aid finder tool that calculates which product and style may be appropriate for a patient based on lifestyle and social needs.
• More information about what makes Starkey unique within the hearing healthcare industry. • A new site architecture that provides an excellent user experience. • And more!
Brent Edwards Elected Fellow of the Acoustical Society of America Starkey’s Vice President of Research, Brent Edwards, Ph.D., was elected a Fellow of the Acoustical Society of America (ASA) in recognition of his contribution to the understanding and treatment of hearing impairments. The ASA is the premier international scientific society in acoustics devoted to the science and technology of sound.
William F. Austin Honored with 2011 Jefferson Award
Starkey Named to Star Tribune Top Workplaces 2011
William F. Austin, CEO of Starkey and founder of the Starkey Hearing Foundation, was among 18 Americans to receive a 2011 Jefferson Award, the nation’s highest honor for public service. Austin was honored for Outstanding Service by an Entrepreneur for decades of work bringing the gift of hearing to those in need through the Starkey Hearing Foundation.
Starkey was ranked number 16 on the large employers list for the Star Tribune Top Workplaces 2011 in Minnesota. The ranking was based on employee survey information and recognizes the most progressive companies in Minnesota based on employee opinions about company leadership, communication, career opportunities, workplace environment, managerial skills, pay and benefits.
The 39th annual awards, dubbed the “Nobel Prize” for public service, were presented in June. Other honorees included actress Marlo Thomas; Chicago White Sox and Chicago Bulls owner Jerry M. Reinsdorf; U.S. Supreme Court Associate Justice Ruth Bader Ginsburg; and former Atlanta Falcons running back Warrick Dunn.
Hearing Innovation Expo
For more information on current job openings at Starkey, visit www.starkey.com/careers.
Hearing Innovation Expo 2012 at the New Cosmopolitan of Las Vegas ™
The Hearing Innovation Expo, a new global event for independent hearing care professionals, will be held January 4–7, 2012 at the Cosmopolitan of Las Vegas. Media Mogul Sir Richard Branson and former President Bill Clinton will be among a number of featured keynote speakers at the event, which will present the latest innovations in hearing science and technology, patient care and business practices. Sponsored by Starkey Group, the Expo will feature industry thought leaders, world-class scientists and Fortune 500 executives, and will deliver new and exciting content relevant to today’s cutting-edge hearing industry professionals.
Contact your Starkey Group Representative or visit HearingInnovationExpo.com for more information. 62
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