VOLUME 1 | ISSUE 1 | 2011
POWER
comes in SMALL PACKAGES One California audiologist discovers less is more
Starkey Audiology Series Improved Patient Satisfaction in Hearing Aid Fittings
Answers from an Expert
PREMIERE
ISS UE !
Q&A Session with Catherine Palmer, Ph.D.
Letter from the Editor Snail mail, publications, email, text messages, social media, phone calls and more – in this age of information, getting facts and the ideas we need isn’t a matter of access, it is a matter of sorting through the clutter to get down to what really matters. Innovations was conceived with precisely that in mind: Information for busy clinicians about technology and processes with optimal patient care and successful practice management in mind. “Innovation” has been described as a process that takes an idea that is possible with current technology and desirable to those who may use it, and turns it into a viable offering in the marketplace. This premiere issue of Innovations holds true to the name with traditional concepts such as transcranial CROS fittings implemented with an unconventional twist; wireless connectivity implemented in a manner that makes it convenient and practical for the first time; and a different way of summarizing and communicating solid information important to any clinical practice. Published by Starkey, Innovations will be distributed quarterly with a broad selection of content, much of which will be focused on practical information related to your patients and your practice, and not necessarily tied to Starkey products and services. As an example, take a good look at Catherine Palmer’s Q&A about objective verification of hearing aid fittings in this issue. She makes some very good points about probe measurements and why they are important for every fitting. Innovations will also be the new home for the Starkey Audiology Series, started last year under the guidance of Barry Freeman, Ph.D. This issue of Innovations features “Patient Satisfaction in Hearing Aid Fittings,” a contribution from Gyl A. Kasewurm, Au.D. Gyl’s common-sense approach to improving the patient experience is a straightforward lesson on how to keep our patients satisfied by going well beyond the performance of the hearing aid, and paying attention to the person who is wearing the device. I look forward to hearing from you with questions, comments and suggestions for Innovations. Communication, by definition is a two-way effort, and we will need your input to ensure that we meet that definition.
Dennis Van Vliet, Au.D. Editor, Innovations Senior Director of Professional Relations Starkey Laboratories, Inc.
Welcome to the premiere issue of Innovations, a quarterly publication providing practical information related to your patients and your practice.
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Clinical Corner One California Audiologist Discovers Less is More Tell us what you think
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Expert Q&A
Blog.starkeyinnovations.com
Insight from Catherine Palmer, Ph.D.
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Starkey Audiology Series
giving back
The Gift of Hearing
Patient Satisfaction in Hearing Aid Fittings 029
Sounding Board
TABLE OF CONTENTS
Help Us Help You
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Research to Reality
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Development of SoundPoint
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Sound Advice
Employee Profile
Staff Spotlight: Joyce Rosenthal
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How to Change Receivers in Inspire速
Technology Spotlight
Invisible-In-The-Canal Hearing Aids
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Technology Review
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Seamless, Effortless and Truly Wireless
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New to the Field
Learning corner
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Continuing Education Tips & Tools
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Compression Made Simple
Tools & Resources
Find the Answers on StarkeyPro.com
Featured Contributors to this Issue: Brent Edwards, Ph.D. Jason Galster, Ph.D.
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Business Intelligence
Better Information. Better Results.
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starkey News
News & Views
Gyl Kasewurm, Au.D. Catherine Palmer, Ph.D.
Innovation The Innovation Process in Action: The Development of SoundPoint
Brent Edwards, Ph.D. Vice President of Research, Starkey Laboratories, Inc.
RESEARCH TO REALITY
Development of SoundPoint
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Over the past two years, during the development of SoundPoint, Starkey Research gave several “sneak peeks” to hearing care professionals visiting our labs, and the response was almost unanimous enthusiasm. “When can I have this? I need it now,” was a common response. It became clear early in development that the invention yet to be named SoundPoint was destined to become an innovation once we introduced it to the clinic as a part of the Inspire® 2011 software.
Innovation is the useful application of invention and provides newly-created value while often requiring a change in behavior by those who benefit from it. One source of innovation is connections between different fields of expertise: the discovery of technology in a field different from your own and applying it to a need in your own field. SoundPoint is one example of Starkey Research’s commitment to innovation.
Where does this enthusiasm toward SoundPoint come from? It results from SoundPoint’s potential value to the hearing aid fitting process. Edgar Villchur, one of the original creators and advocates of multiband compression in hearing aids, once said that multiband compression is only as good as it is fit. If a well-designed compressor is poorly fit, the patient might as well be wearing linear technology. Despite advances in hearing aid technology, the proper fitting of multiband compression to a patient’s needs remains a challenge. Many audiogram-based fitting algorithms address the challenge of prescribing compression parameters, but there are many reasons why these first fits are not the best fit for an individual. As a result, manual fine-tuning of a hearing aid by the hearing care professional has become an expected facet of patient care.
The Solution SoundPoint was developed as one solution to these challenges. It solves fitting difficulties by allowing patients to assist in the fine-tuning of their hearing aids. There were many challenges in the development of SoundPoint, and those challenges and the research behind its development are detailed here. The technological basis for SoundPoint comes from a synergy between the fields of musical instrument synthesis and hearing aids. In the music synthesis field, David Wessel (currently a professor at UC Berkeley) faced the challenge more than 30 years ago of how to create a very simple and intuitive interface that can control a complicated musical instrument synthesizer with dozens of adjustable parameters. This challenge is similar to one that researchers in the hearing aid field have faced: how to create a simple and intuitive
About the Author: Brent Edwards, Ph.D., joined Starkey in 2004 and is responsible for developing and executing the organization’s corporate research strategy worldwide. Edwards founded and developed the Starkey Hearing Research Center where he leads a team of inter-disciplinary scientists and engineers conducting long-term research on hearing impairment and hearing aid technology. Edwards received his Bachelor of Science Degree in Electrical Engineering from Virginia Polytechnic Institute and State University, his M.S. and Ph.D. in Electrical Engineering and Computer Science from the University of Michigan, and was a Postdoctoral Fellow in Psychology at the University of Minnesota.
The light-colored squares illustrate the area on the SoundPoint space that has already been navigated by the patient. The colored pushpins represent the patient’s preferred sound quality locations; the circled pushpin represents the location on the space to which the patient is currently listening; and the star indicates the most preferred location on the space – “the winner.”
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interface that controls a complicated multiband compressor with dozens of adjustable parameters. One of the earliest papers on Wessel’s synthesizer technology was published in 1978, and Wessel has continued to improve his technology with complex engineering and psychoacoustic design considerations over the years since. We saw it in action at his research center and instantly recognized its potential as a hearing aid selftuning system. Once the connection was made between his technology in the computer music field and the fine-tuning needs in the hearing aid field – the first stage in the innovation process had begun.
Once the SoundPoint prototype was complete, more than a year of experiments were conducted to validate that this tool produced repeatable, reliable, and meaningful results when used for self-tuning of a hearing aid. When we were satisfied that people could easily use this tool and that the self-tuning was successful, a series of rigorous clinical experiments began at Starkey Research in Minnesota to ensure that SoundPoint produced beneficial improvements to the first fit and to determine how it compared to finetuning conducted by an experienced audiologist. Additional work was completed to “fine-tune” SoundPoint, ensuring that patients couldn’t negatively impact their fittings by reducing gain and audibility. Finally, patient satisfaction with SoundPoint was measured and compared to satisfaction with a traditional fine-tuning procedure. This was an important measure because involving patients in the fine-tuning process with SoundPoint produces a sense of ownership with the final fit, helping them understand that their final settings are the best fit for their individual needs.
Research Challenges and Testing There were many scientific and technological challenges to be overcome at Starkey Research before we could integrate Wessel’s technology into a hearing aid fine-tuning system. The project began at our research center in Berkeley, where we translated the technology to simultaneously adjust dozens of multiband compression parameters rather than dozens of music synthesizer parameters. We then gathered a significant amount of psychoacoustic data to design an intuitive user interface so that changes made by a patient result in perceptually coherent adjustments to sound quality, even though the compressor parameters changed dramatically.
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translate into increased success with their hearing aids, fewer hearing aid returns, and increased satisfaction with the clinical process.
The Research Team Many researchers were involved in the research, development and testing of SoundPoint. Four significant contributors to its success are: 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 explore the perceptual consequences of hearing loss and hearing aids. Fitz has a Ph.D. in electrical engineering from the University of Illinois at Urbana-Champaign.
The results of these experiments were successful and are detailed in upcoming journal publications. Not only did the majority of our subjects prefer the SoundPoint self-tuning over the fine-tuning of an experienced audiologist, but even those subjects who preferred the finetuning by the audiologist said that they would rather assist in future fine-tuning with SoundPoint. This preference demonstrates the confidence that SoundPoint provides because of the patient’s involvement in the process.
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, and Hearing Association and worked as a clinical audiologist at the Indiana University Hearing Clinic, where she received her Ph.D. She has also taught a variety of undergraduate and graduate courses in audiology at Indiana University and Butler University. While completing her Ph.D., her research focused on auditory perception, and more specifically, on the sound segregation abilities of normal-hearing and hearing-impaired listeners. Valentine holds a bachelor’s from Lenoir-Rhyne College and a master’s in audiology from the University of Tennessee.
Needless to say, not every patient would want or enjoy this control over their hearing aid finetuning, but there are many patients who do, and our data suggests that these patients will have increased satisfaction with their hearing aids and confidence in the final fit, which will likely
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 the effects of hearing aid
Kelly Fitz, Ph.D. – Digital Signal Processing Engineer
Susie Valentine, Ph.D. – Research Audiologist
J. Andrew (Drew) Dundas, Ph.D. – Research Audiologist
Dan Edgar – Software Engineer
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 investigations of vestibular assessment tools, hearing aid outcome measure development and tests for the detection of cochlear dead regions. Dan Edgar is a Software Engineer, specializing in iPhone, iPad and Windows application development. Throughout his seven years at Starkey he has focused on innovating within the Inspire fitting software with the goal of increasing patient and audiologist understanding. Edgar has a B.Sc. in computer science from Minnesota State University – Mankato.
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RIC
Seamless, Effortless and Truly
how to change receivers in
i n s p ir e
®
Jason Galster, Ph.D.
The receiver-in-canal (RIC) product has gained
Starkey’s Wi Series™
Features
significant popularity over the last few years.
Starkey’s Wi Series (pronounced “Wi” as in wireless) hearing aid family introduces the wireless IRIS™ Technology platform. Wi Series is the first hearing aid to wirelessly stream stereo audio, program wirelessly and offer robust binaural signal processing – all without the need for a relay device or cumbersome pairing. Other wireless hearing solutions use comparatively high or low frequency bands for data transmission, but Wi Series transmits inside the Industrial Medical Spectrum at a frequency of 900 MHz, offering an ideal signal for far-field and ear-to-ear connectivity.
Wi Series with IRIS Technology offers an array of advanced features including:
receive many calls regarding fitting support. Here are some of the most common questions:
When fitting a RIC, how should I measure cable length?
Sound advice
• T ake careful measurements using the universal measurement tool to ensure an accurate fit. •W e model the receiver to be built at the top portion of the custom mold, so it is crucial that you measure to the top of the ear canal opening for receiver cable length. If you measure to the middle of the canal opening, you may find that your cable length is typically too long. • T his process is also true for open receiver options to get the snuggest fit of the wire to the ear.
How do I change a receiver matrix or acoustic options in Inspire? Changing the receiver matrix and acoustic options in the software is a relatively simple process, but a process that can be easily overlooked. The
This figure illustrates the “Acoustic Options” icon at the lower left of the Inspire Quick Fit screen. Clicking on the icon reveals a dropdown screen containing the “arrow chasing arrow” icon that generates a popup figure for receiver gain selection.
quickest, most efficient way to change a matrix configuration or an acoustic option is as follows: • Read the instrument • Go to Quick Fit screen
1. N avigate to the acoustic options icon and select open or occluded fit.
2. N avigate “arrow chasing arrow” and select appropriate matrix.
3. T he selected matrix will reconfigure for the best fit.
In order to maintain optimal wireless signal quality, Wi Series uses Adaptive Frequency Agility to avoid wireless interference, maintaining signal quality. Adaptive Frequency Agility uses a “look ahead” approach to data transmission. The hearing aid monitors wireless channels within the 900 MHz frequency band, constantly searching for an optimal channel. If an adjacent channel offers improved signal quality, the system will dynamically and seamlessly transition to that channel. Eighteen different frequencies in the 900 MHz spectrum are available to choose from, virtually eliminating bothersome interference in typical home environments.
• B inaural Spatial Mapping, a new protocol designed to query, analyze and map the acoustic space surrounding a patient, and apply the appropriate processing strategy for directionality and noise management. Binaural Spatial Mapping creates a virtual layout of the acoustic environment around the listener, sharing data between ears to allow more accurate and efficient algorithm function. This spatial identification of speech and noise sources allows for improved performance of the directional microphone and digital noise reduction systems.
technology review
Manager of Clinical Comparative Research, Starkey Laboratories, Inc.
Our audiology and technical support teams
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W ir e l e s s
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way people hear in noise by allowing the listener to focus on the sounds they want, and reduce the ones they don’t.
obscure the score of an exciting sports event. SurfLink Media addresses those needs:
o Simply plug almost any form of audio – including a TV, radio or MP3 player – into SurfLink Media and stereo sound is streamed directly to any Wi Series hearing aids in range without pairing or a body-worn relay device. Hearing aids may be programmed to receive the streaming in selected memories, or disconnected as desired.
o I ntelligent Media Mobility seamlessly transitions people to different devices as they move around their homes.
o Eliminates audio delay and lip-sync issues* and allows for adjustable range and volume control.
• PureWave Feedback Eliminator, the industry standard in feedback control, ensures wide fitting ranges and a fast response to more complex feedback.
Wi Series is available in 40-gain to 71-gain Absolute Power receiver-in-canal (RIC) hearing aids.
• S ynchronized user adjustments allow the hearing aids to be programmed so a single aid will adjust volume or memory for both – eliminating the need to manually change two instruments and eliminating the risk of inadvertently mismatched adjustments. I t has become increasingly common for hearing aids to be designed without volume controls. This is partially due to the success of compression strategies and the design aesthetic of modern technology. Yet, many patients find value in a volume control. With the IRIS Technology logic in place, one device can be programmed to make volume adjustments and the other to make memory changes. Patients won’t need to compromise in their selection of volume or memory control. • B inaural Telephone Mode automatically places the phone-side hearing aid to Automatic Telephone Response or Telecoil mode while attenuating the off-side hearing aid. • Advanced HydraShield®, the proprietary moisture control system that makes the hearing aids resistant to water, humidity, perspiration and corrosion. •V oice iQ, the noise management and speech preservation system designed to change the
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• L ive Real Ear Measurement, directly measuring sound pressure levels in the ear canal to ensure audibility and target match for conversational and loud sounds.
Accessories Wi Series connects with SurfLink™ accessories and an optional remote control: • T he SurfLink Programmer, combined with IRIS Technology and the Inspire® fitting software, provides flexible direct-to-hearing aid wireless programming. Features:
oC onnects easily to a fitting computer via standard USB connection and automatically detects Wi Series hearing aids in seconds.
o Has a range of at least 20 feet, allowing patients to move around the fitting room during counseling and demonstrations with no additional hardware.
oU ses Adaptive Frequency Agility to avoid interference, allowing several programmers to be used in the same office.
o Engineered to be up to four times faster than HiPro and twice as fast as NOAHLink and nEARcom.
• F or patients, SurfLink Media provides the first setand-forget media streaming solution. Hearing care professionals note that it is common to have patients report difficulty hearing the television. A spouse may be bothered by the level of the television, a favorite news anchor may be difficult to understand, or closed-captioning may
o Allows multiple users to be connected to the same media source.
• Remote controls come with a selection of three interchangeable faceplates, offering basic, intermediate, and advanced configurations that allow patients to adjust memory and volume settings, mute the hearing aids or go in and out of streaming mode. Wi Series lives up to the promise of wireless. It is available in receiver-in-canal (RIC) hearing aids ranging from 40-gain to the 71-gain Absolute Power and features the industrial design language that has won 12 design, medical and consumer electronics awards. Wi Series is available at three technology levels – Wi Series i110, Wi Series i90 and Wi Series i70 – making this truly wireless solution an option for a wide range of patients.
About the Author: Jason Galster, Ph.D., is Manager of Clinical Comparative Research with Starkey Laboratories, Inc. He investigates the clinical outcomes of modern hearing aid features while ensuring that product claims are accurate and backed by supporting evidence. Galster 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.
These features and accessories are only some of the highlights of Wi Series products. IRIS is a unique technology designed and implemented by Starkey with the needs of patients and professionals in mind. *Latency is unnoticeable according to International Telecommunications Union standards.
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POWER comes in SMALL PACKAGES
Clinical Corner
One California audiologist discovers less is more
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Cerritos, Calif., Audiologist David DeKriek knew he had a challenge when he met A.S., a 17-yearold male with total hearing loss in his left ear and normal hearing in his right ear. A.S. was accompanied by his mother, who explained that her son had suffered a sudden loss several months ago. After a series of tests and treatments by an ENT physician, they were told that the hearing loss would be permanent. They were offered few options for help and were eventually referred to Dr. DeKriek’s community-based private practice. In the needs assessment, it was clear to DeKriek that A.S. was having difficulty compensating for the sudden loss of hearing, but that he was not willing to make many convenience or cosmetic sacrifices. His mother, on the other hand, was highly motivated to see that all avenues were pursued so that A.S. had the best chance for success in school in the immediate future and later in life. That dedication convinced DeKriek that both mother and son were dedicated to finding a solution. “I would not have gone ahead with the recommendation for the transcranial CROS if the mother hadn’t been so insistent that they could make it work,” reported DeKriek.
Conventional treatments with CROS or BAHA were ruled out for cosmetic and convenience reasons. After some simple testing, it was determined that stimulation of the “dead” ear did not yield negative consequences, and that information crossed over to the normal ear in a predictable manner. Because a transcranial CROS might be an option, an ear impression was taken to better assess the size of the ear canal, and the ability to use a power receiver in a custom product. In spite of the fact that A.S. was not a large individual, he was “lucky” enough to have very large ear canals. The impression was sent in to Starkey with a request for as much power as possible for a transcranial CROS. When the finished product arrived, DeKriek was surprised to see a 312 battery-powered custom aid and even more surprised to see the faceplate fit well past the first bend of the ear canal, yielding a very nice cosmetic result. A.S. accepted the hearing aid, and has been wearing it regularly in social and educational settings. He reports that he really appreciates the benefit when people are speaking on the side of his impaired ear when he would otherwise not be aware that they are talking to him.
Objective assessment was completed using the Verifit real-ear measurement system following a procedure described by Valente et al in the American Journal of Audiology (Vol. 4, No. 1, 1995). The procedure calls for establishing behavioral thresholds with an insert phone in the ear with the total loss, reflecting unmasked crossover to the normal ear. SPL levels obtained simultaneously in the ear canal with the probe microphone system reflect objective target references needed for audibility of the crossedover signal. Aided levels recorded at different levels and overlaid with the targets provide an objective illustration of the audibility to the normal ear via stimulation of the poor ear. Figure 1 shows reasonable audibility (speech spectrum energy above the transcranial thresholds) in the mid frequency ranges for speech at 65 and 75 dB SPL, verifying the patient’s reports of awareness of speech on the left side and subjective benefit.
Figure 1: This figure displays the in-situ sound levels from deeply fitted CIC hearing aid in response to soft, average and loud speech stimuli. The shaded area represents the maxima and minima of the long term average speech spectrum (LTASS.) Audibility in the opposite ear is demonstrated by the speech spectrum above the blue threshold line. In this case, portions of the average and loud speech spectra are audible, and meet the goal of alerting the user to sounds on the nonfunctioning side.
The idea of transcranial CROS fittings has been around for decades, but the confluence of issues such as potential for feedback, poor cosmetics, and inconvenience in patients with normal hearing in one ear has resulted in the technique being infrequently recommended. “The advent of very effective feedback reduction, along with the possibility of very small custom devices has reduced the objections to a point where I can now consider the recommendation for appropriate patients,” said DeKriek. From the patient’s perspective, A.S. is very grateful for the help and additional awareness that the transcranial CROS brings to his daily life. “I’m very glad that we did this,” he commented during a recent visit to DeKriek’s office.
Figure 2: Real-ear probe in place with hearing aid.
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Real-Ear Verification Catherine Palmer, Ph.D. Associate Professor, University of Pittsburgh
verifies audibility and can convince them that being annoyed by all those sounds for a few weeks will pay off as their brain adjusts and they have access to the sounds they need to improve communication. Believe me, when we re-fit individuals appropriately and describe what we are measuring in order to do it correctly, they are not only convinced to go through the few weeks of adaptation but they are very aware that being asked “how does that sound” may have been an inadequate way of fitting their hearing aids originally.
Real-ear probe microphone measures are a verification technique; they are not a treatment.
We have heard for years that real-ear verification of hearing aid fittings is the standard for care, yet there continues to be many of us who, for a variety of reasons, do not include this step in our fitting protocols. Even Starkey’s Live Real Ear Measurement system that makes measurement of SPL in the ear canal about as easy as it can be, doesn’t guarantee that clinicians use it. Let’s look
expert q&A
to an expert who is a strong advocate for real-ear
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verification, and ask her about the obstacles that keep us from following the practice. Catherine Palmer teaches, presents, and publishes both research-based and educational articles in the area of amplification. Palmer sees patients every week and is actively involved in fitting hearing aids as part of the UPMC Audiology practice.
IN (Innovations): If someone has a very busy practice
and a good reputation in the community where she has been practicing for years, her return for credit rate is very low, and her patients are satisfied with their hearing aids and service, then why should she change practice patterns?
CP (Catherine Palmer): Increasing business and/
or reducing returns for credit will never be the motivator for verifying amplification appropriately. In fact, the way we have traditionally measured hearing aid success (the patient kept the hearing aids) could be considered a hindrance to best practices. This is, in part, due to the fact that we spend quite a bit of time helping patients have realistic expectations (and rightfully so). We are clear that hearing aids do not return normal hearing, the individual will still have difficulty in some noisy situations, etc. So, when the patient is not doing all that well, they don’t know how “not well” they should be doing based on our setting of their expectations. They keep the hearing aids and figure that it is as good as it can be. Unless, of course, they come to a clinician who actually
The treatment is audibility.
IN: A hearing care professional has an expensive
REM system gathering dust in the corner. Apparently, the practitioner doesn’t find value in taking the time to measure real-ear data in the fitting process since he ends up changing the parameters anyway. What good are the measurements if he ends up changing things to satisfy the patient?
CP: One thing we need to be careful about
is defining what we mean by “doing real-ear measures.” There are actually many different types of measurements one could do and some will certainly be more useful than others. In addition, just “doing real-ear measures” isn’t useful unless you do something with the data you have collected. It needs to impact how you change the hearing aid parameters or how you counsel the patient. In addition, it seems that many people have confused “real-ear measures” with a treatment. As if we would need efficacy data to show that using real-ear measures
produces a “better” outcome (however that might be defined). Real-ear probe microphone measures are a verification technique; they are not a treatment. The treatment is audibility. There are lots of data (not to mention that it is common sense) that in order to improve communication, the hearing aid must make a range of sounds (soft to loud) audible but not uncomfortable. We know from several publications that the “first fit” program used by manufacturers does not guarantee audibility. And just to be fair, none of the manufacturers claim that they do. The first fit programs are just a starting point (and thank goodness we have a starting point or we’d be at this all day!). So, the real-ear probe microphone measure of audibility of the hearing aid output within the dynamic range (threshold to UCL displayed in dB SPL) is currently the most efficient way to establish audibility across frequency at several input levels. There are other ways to do this, but they all take much more time. Some people may argue that they don’t find taking the time to measure real-ear data helps them in the fitting process. Well, it depends on what they mean by “helping.” This is the only efficient way to know whether or not you have returned audibility to this patient for soft, moderate, and loud inputs across frequency. This is what they are paying you for, and they are paying quite a bit. Indeed, they are paying for your expertise/years of education and if you are not performing a verification measure that can shed light on what might need to be adjusted to achieve maximum communication ability (even if they don’t love how it sounds at first), then you are not using either your education or your expertise and you probably shouldn’t be charging for them. So, real-ear probe microphone measures won’t “help you” make more sales or lower your return rate (those are probably already pretty good based on the discussion above); they are essential in doing the job the patient believes you are doing – setting the hearing aid parameters in order to maximally improve his/her communication.
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IN: A hearing professional is continually frustrated
by trying to achieve target matches. The hearing aid manufacturer’s software says that she should be on target, but she finds it nearly impossible to get a satisfactory match using an independent measurement system. What is wrong?
CP: The manufacturer’s screen is showing
About the Author: Catherine Palmer, Ph.D., is an Associate Professor in the Department of Communication Science and Disorders in the School of Health and Rehabilitation Sciences and in the Department of Otolaryngology in the School of Medicine at the University of Pittsburgh. Palmer serves as the Director of Audiology for the University of Pittsburgh Medical Center and directs the Au.D. program for the University of Pittsburgh.
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you an estimate of how the hearing aid is performing in your patient’s ear. Because the manufacturer’s software can’t include your individual patient’s ear canal dimensions (e.g., real-ear to coupler difference) or the specifics of the actual hearing aid you are fitting (how long is the earmold or end of the custom product, where is the microphone seated, etc.), it is estimating the final response. When you put a probe microphone down the ear canal, you are measuring the actual output. These are the data that matter. So, you have general “targets” that include threshold and UCL of your patient plotted in dB SPL. This provides you with the dynamic range. Ideally, you’d like the output for soft, moderate, and loud sounds to fall within this range across frequency. Of course, this isn’t always possible because of the amount of hearing loss or because of the limitations of hearing aid bandwidth (e.g., there may not be any response past 5000 Hz). By doing the measures, you know where you can make sounds audible and where you may need to compromise. This really empowers the clinician in terms of expressing realistic expectations and counseling the patient. You also can have NAL NL2 or DSL v.5 targets appear on the screen. These are evidence-based targets that help guide you in terms of where you should be pushing for audibility and where you may need to compromise. These are guides, not rules. Because you can see the output of the hearing aid plotted against the dynamic range, you do not have to feel married to these targets. They do, however, provide appropriate guidelines for your fitting. Again, this is where your expertise about hearing loss, amplification and this
individual patient comes into play. If hearing aids really could be fit simply through first fit or simply by exactly matching targets, then we would not need graduate level-educated individuals engaging in these activities.
The use of real-ear probe microphone measurements can definitely save you time.
IN: It may be difficult for a hearing professional who
works in an ENT clinic to justify the extra cost for external equipment or taking the extra time to do real-ear measures with an integrated system to the practice manager. He and the physicians argue that the patients seem satisfied enough and that spending the money will only reduce profitability and reduce productivity. What arguments could this person use?
CP: It continues to be very frustrating for
audiologists to find themselves in a position where they have to “ask” someone else whether they can have needed equipment. We need to change this conversation and indicate that hearing aids cannot be fit in this office without the appropriate equipment. You would not ask the physician to provide a treatment for which he/she did not have appropriate equipment. You certainly can point to every amplification guideline (AAA and ASHA) to show that the use of real-ear probe microphone measures is considered the standard in hearing aid fitting and has been established as best practice. But again, the argument that the use of the correct measurement technique will somehow change your number of sales or return rate won’t work because it isn’t true. The use of real-ear probe microphone measurements can
definitely save you time once you are comfortable with placing the probe mic and taking the measurements. You don’t waste time with useless fine-tuning because the picture is literally worth a 1000 words (1000 words saved). Now you can counsel the patient from the position of knowing which sounds are audible and which ones aren’t, what they will need to adjust to and what will still be difficult. The amount of fine-tuning related to repeatedly asking the question “how does this sound” could be a waste of time and does not set the audiologist up as the expert they should be in this situation.
IN: Some hearing professionals say they simply do
not have time to fool around with probe mic measures when patients need so much counseling. Do probe microphone measures substitute for face-to-face counseling about hearing loss and adapting to hearing aids?
CP: As I mentioned above, the real-ear probe microphone measures should save time and focus your counseling. Even showing the patient where we can achieve audibility and where we can’t or using the graph to show them why they have to go through these first few weeks of full-time use to get used to these newly amplified sounds makes our counseling more meaningful to the patient. Because we don’t waste time repeatedly asking patients “how does this sound” when they don’t know how things should sound, we have much more time to teach them how to use the hearing aids and to counsel them about what to expect. Because patients know you have a measurement that you are relying on, they also are much more willing to try to adjust to these new sounds. These measurements make sense to our patients; we just need to convince ourselves!
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Compression M a d e
S im p l e
Whether you are new to the field of audiology or have been fitting hearing aids for years, the basics are an important part of your success as a professional. This article is a quick refresher on compression and the associated nomenclature.
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Dynamic Range of Person with Normal Hearing
)Bd( leveL gniraeH
Hearing Level (dB)
-10 0 10 20 30 40 50 60 70 80 90 100 110 120 125
)Bd( leveL gniraeH
New to the Field
Dynamic Range of Person with Normal Hearing
250
500
1000
2000
4000
4000
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8000
120 110 100 90 80 70 60 50 40 30 20 10 0 -10
Dynamic Range of Person with Hearing Loss
Compression continues to be one of the least understood parameters of hearing aids. With today’s sophisticated hearing devices, knowledge of compression needs to be part of any hearing professional’s core skills. It is always useful from time to time to go back to basics and review the fundamentals, especially with compression. Compression Vocabulary •D ynamic Range: The dynamic range describes sound levels above an individual’s threshold of hearing but below the levels perceived as uncomfortably loud. A person with sensorineural hearing loss typically has a narrowed dynamic range. This narrowed dynamic range is the rationale for using compression – the need to “compress” the full range of sounds into the “narrow” range. • C ompression Threshold Kneepoint (TK): The sound pressure level at which a change in compression is activated. An input/output curve describing the characteristics of an amplifier may have more than one TK describing transitions from one compression or processing strategy to another. • Input Compression: The amplifier detects signal levels and applies compression in the signal path before the volume control. Adjustment of the volume control also affects the maximum output of the hearing aid. •O utput Compression: The circuit detects signal levels in the signal path after the volume control and the maximum output of the hearing aid is independent of the volume control adjustment. Output Limiting Compression is generally this type. • C ompression Ratio (CR): The amount of change in output relative to a change in input. Always described in an “X”:1 format.
Example: a 2:1 CR means that for every 2 dB increase in input the hearing provides a 1 dB increase in output. ide Dynamic Range Compression (WDRC): A wide •W range of input levels are subject to compression. To achieve this, WDRC uses low compression threshold kneepoints, typically between 20-50 dB. Compression Ratios may vary, but the WDRC strategy will allow for lower compression ratios than a compression limiting strategy that uses higher kneepoints.
• I nput/Ouput Curve (I/O): A visual representation of the amplifier characteristics over a range of inputs. • Channels: A hearing aid channel is a subdivision of frequencies that are created by a filter or series of filters. In addition to expansion and compression, most signal processing features such as digital noise reduction and feedback suppression operate on a channel-by-channel basis. With more channels available comes more flexibility to account for frequency specific variations in dynamic range. Example: the Starkey Wi Series™ i110 and S Series™ iQ 11 devices have 16 channels, which allow for very finely tuned compression across the frequency response.
19
Patient Satisfaction
in Hearing Aid Fittings
Starkey Audiology Series
Gyl A. Kasewurm, Au.D. Professional Hearing Services, St. Joseph, MI
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For many years, the hearing industry has can conclude that focusing on patient satisfaction recognized patient satisfaction as a key is good for patients and good for business. component in the successful fitting of hearing aids. Kochkin’s latest survey results point to While hearing aid technology, fitting science, audiologists as being an obstacle to improving and professional education have all improved patient satisfaction (Kochkin, et al, 2010). The dramatically in the last ten years, MarkeTrak MarkeTrak VIII studies indicate survey led to the little progress in conclusion that the percentage of typical hearing aid patients who are than four million people fitting protocols have “satisfied” or “very in this country alone who need hearing aids failed to keep pace satisfied” with will not purchase them because of a negative with technological their hearing aids report from someone they know. improvements. In (Kochkin, 2010). this report, the Additional Kochkin authors report data suggests that that the majority more than four million people in this country alone of audiologists fail to verify that patients are who need hearing aids will not purchase them deriving adequate, let alone optimal, benefit from because of a negative report from someone they their hearing aids. know (Kochkin, 2007).
More
The potential financial impact of these statistics on the industry as a whole is staggering, and the effect of such negative word of mouth advertising could be fatal to an individual audiology practice, considering that dissatisfied patients tell at least five times more people than patients who are satisfied. In addition, market research indicates that satisfied patients pay less attention to the competition, are less price sensitive and cost less to serve than dissatisfied patients. Therefore, one
A study conducted in England confirmed similar findings and found an 18% improvement in patient satisfaction for patients who were fit using real-ear measurements (REM) versus those not fit with REM (Kochkin, et al, 2010). This information suggests that the first step on the road to patient satisfaction should be a comprehensive fitting protocol that ensures a patient is deriving adequate gain, optimal benefit and no loudness discomfort from their hearing aids.
Adhering to a best practices protocol consisting of a comprehensive battery of tests, including measures of loudness, discomfort and speech in noise testing may also help separate one audiology practice from another. Long time hearing aid wearers who have been fit with a comprehensive protocol often comment, “I have never had my hearing tested so thoroughly before.” It is commonplace today for our patients to search the Internet for information before choosing a hotel or planning a vacation. This popular trend is spreading to the healthcare industry, making the patient experience a new competitive battleground. As potential patients become more knowledgeable about what to expect when receiving hearing healthcare services, pressing “best fit” in the manufacturer software and scheduling a recheck appointment in a week will not be enough to convince them to entrust their hearing health to us. Savvy baby boomers will expect more for their average investment of $4,000. Increased consumer awareness reaffirms the need for all clinicians to perform a comprehensive battery of tests and outcome measurements for every patient.
experience, and 82% of consumers that had a bad experience told others about it (RightNow, 2010). Findings specific to audiology concluded that patient satisfaction ratings were influenced more by how a patient was treated than by the sound quality and intelligibility of the hearing devices (Wong, 2003).
A segment of the retail industry has garnered success by focusing on the customer experience. Ritz-Carlton Hotels attempt to morph a simple A review of recent healthcare trends indicates transaction into a transformational experience. With that there is a growing interest in the value of each stay, hotel associates observe the preferences the patient experience of an individual – favorite and how it affects type of pillow, preferred patient satisfaction. radio station, late night of consumers stopped The emerging age snacks, etc. – and enter doing business with a company due of consumerism in this information into healthcare is forcing a database to form a to a bad customer experience. hospitals to reexamine lasting relationship with their traditional their guests. While Ritzpractices and provide Carlton Hotels go to greater sensitivity and responsiveness to patient extremes to please their customers, it doesn’t take preferences. Unhappy patients can be very costly such efforts to make and keep our patients happy. to a business. According to a survey conducted Simply greeting a patient with a smiling face as in 2009 by Harris Interactive, a global research soon as they walk through the door will make a marketing firm, 86% of consumers stopped doing good impression, and you can imagine how the business with a company due to a bad customer patient will feel when we address them by name.
86%
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Maintaining a good patient experience isn’t easy and will require ongoing training and regular reevaluation. Receptionists should be trained to correctly answer patients’ most commonly asked questions, including basic queries about technology. There is no larger deterrent to a good experience than making a patient wait an extensive amount of time while you finish an
appointment or help a patient who “walks in” for service. Long wait times show a lack of respect for a patient’s time. Running behind schedule is unavoidable at times, but when it happens, apologize for the delay and make certain the patient is kept informed of the anticipated wait time. If the wait becomes excessive, give the patient the option of rescheduling and then make certain that you don’t make them wait at their next appointment. Patients usually don’t mind waiting for a professional they like and trust and will understand in the event of an unavoidable short delay. However, patients who experience repeated delays may choose another provider when it comes time to repurchase. Since the telephone can be a patient’s first contact with a business or professional, it makes good business sense to have a real person answer the phone. It may be less expensive to have a machine, but it isn’t very patient friendly, especially for patients with hearing loss who may have difficulty hearing and understanding the myriad of choices. Whenever possible, avoid placing a caller on hold for a long period of time. If you expect to be away from the phone for more than a minute, ask the patient if you can return the call at a time that is convenient for them.
Professional Hearing Services, a patient friendly office in St. Joseph, Michigan.
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It has been reported that less than half of consumers are satisfied with their hearing instruments in difficult and real-world listening situations (Kochkin, 2010). In fact, there has been some evidence to support the notion that many patients reject amplification because they are not prepared for the noise that awaits them in the real world. Including the capability to demonstrate the benefits of better hearing in real-world environments can be a way to improve patient satisfaction. Patients who have lived with the gradual onset of hearing loss may have a difficult time understanding what it will be like to hear well again. Discrimination testing presented at a normal conversational level (45dB HTL) in
the aided versus unaided condition can be an effective way of demonstrating hearing handicap and the potential benefits of amplification. Including multimedia environments for testing procedures can be a possible way of evaluating a patient’s potential performance in the real world. A study conducted by Robinson, Russ, and Siu (2002) suggested that the use of “reallife” simulated environments was an effective way to fine-tune hearing instruments. Results of the investigation indicated that the ability to experience everyday sounds while still in the office helped patients set more realistic expectations for amplification — a big part of any successful hearing instrument fitting. Kochkin (2003) concluded that using real-world environmental testing led to more realistic patient expectations and preferred use gain being accomplished with fewer follow-up visits. The majority of patients who are unhappy will never share those feelings with their professional, but they of course will reveal them to everyone else they know. When a patient takes the time to express dissatisfaction, consider it a second chance to retain their business and welcome the opportunity to “make things right.” It doesn’t really matter who is at fault. The only outcome that matters is that the patient is satisfied. The best way to turn an unhappy patient into a raving fan is to solve their complaint immediately and resolve it completely. In most cases, the resolution requires much less than you were actually willing to do. So what can one conclude regarding patient satisfaction? Hearing aid performance alone is only a small factor in patient satisfaction. Most importantly, we must know conclusively that patients are deriving adequate benefit from their hearing aids, and we also must ensure that patients are treated in a warm, courteous and professional manner during every step of the patient journey.
About the Author: Gyl A. Kasewurm, Au.D., is President of a very successful private practice in St. Joseph, Michigan - Professional Hearing Services. She is known for her hearing services, marketing skills as well as her business acumen. She has published extensively and is a sought-after speaker to present her innovative ideas to help maximize private practice opportunities.
References Cox, R.M. and Alexander, G.C. (1999) Measuring satisfaction with amplification in daily life: The SADL Scale. Ear and Hearing, 20: 306-320. (Available on the web at: www.memphis.edu/ausp/harl/sadl.htm). Kochkin, S., et al. (2010) MarkeTrak VIII: The Impact of the Hearing Healthcare Professional on Hearing Aid User Success. Hearing Review, 17(4):12-34. Kochkin, S. (2010) MarkeTrak VIII: Customer satisfaction with hearing aids is slowly increasing. Hearing Journal, 63(1):11-19. Kochkin, S. (2009) MarkeTrak VIII: 25-year trends in the hearing health market. Hearing Review,16(11):12-31. Kochkin, S. (2007) MarkeTrak VII: Obstacles to adult non-user adoption of hearing aids. Hearing Journal, 60(4):27-43. Kochkin, S. (2003) On the issue of value: hearing aid benefit, satisfaction, and repurchase rates. The Hearing Review, 10(2):12-26. Right Now. Customer Experience Impact Report. http://www.rightnow.com/files/ analyst-reports/RightNows_4th_Annual_Customer_Experience_Impact_Report.pdf. Accessed October 21, 2010. Robinson, J., Russ, D., Siu, B. (2002). Effect of a multimedia fitting tool on final gain settings. Hearing Review, 9(3);42-45. Wong L., Hickson L., McPherson B. (2003) Hearing aid satisfaction: What does research from the past 20 years say? Trends in Amplification, 7(4):117-161.
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800 700 600
Key Points
500
• No additional ad spend
Count
Better Information Better Results
Here are some sample results from an account that used CallSource to help track and analyze calls:**
• Prospects went from 133 to 267
400 300
ppointment ratio went from 38% •A to 73% for new patients
100 0
• T he average cost to acquire a new patient is between $500-$900.
Maintaining a successful practice goes beyond good technical skills. Prospective patients need encouragement and education to seek out care from a hearing professional. Gathering the information and skills to bring new patients into the office and offer a meaningful experience for them requires extensive training and staff development, as well as business and training tools. So, what does that mean? A practice needs the best possible information available to succeed – including the ability to target prospective patients, track performance of advertising and continuously work with staff to ensure patients have the best possible experience. Starkey provides a number of business and training tools for practices, including online and in-person classes, as well as programs like a telephone training program from Starkey and CallSource® Results designed to improve results by training office staff to turn more calls into appointments.
•C allTrack provides tracking phone numbers that can be published on marketing campaign pieces. The different numbers allow for tracking of calls by ad source, day of the week and time of day. ®
August
•O ur University is a collection of four online courses developed to help with opening, handling and closing a call.
New Patient Prospect Calls
October
New Patient Appointments Set
Being both good and efficient is good for business. Adding just one more patient per month can mean an additional $250,000 in five years and $500,000 in ten. And, if you can add one patient and shorten the sales cycle for the hearing aids, it can mean an additional $500,000 in five years and $1,000,000 in ten.
800 700 600
$1,000,000 +
500 400 300
One more patient per month and shorten sales cycle. $6,316,200
200
One more patient per month. $5,880,600
$500,000 +
100
®
This program will yield better results by improving call handling and increasing the percentage of properly booked appointments. Additionally, the data collected can provide insights into the right marketing mix.
September
42%
The Value Proposition
• L eadScore® provides the true number of prospects per marketing campaign by listening to each call and removing solicitations, employee calls, etc. • T elephone Performance Analysis® rates calls against predetermined criteria as well as provides training program recommendations based on a staff member’s skill level and designated areas for improvement.
73%
61%
38%
Calls
Dollars
business intelligence 24
• 58% of hearing aids sold last year were to repeat buyers.*
34%
July
The training program consists of a number of components:
39%
35%
Did You Know?
• It takes approximately 70 calls to acquire 10 new patients each month.
36%
200
$5,336,000
0 1
2
3
10 patients/Mo, 4-yr Cycle
4
5
Years
6
7
11 patients/Mo, 4-yr Cycle
8
9
10
11 patients/Mo, 3-yr Cycle
Data provided courtesy of CallSource. * Data drawn from CallSource’s portfolio of 1,700 Starkey Group customers. **Based on 15% marketing budget for $1MM practice.
To learn more about Starkey's business support and development tools, visit StarkeyPro.com 25
Giftof Hearing
the
Hussein isn’t your typical child; he’s a survivor. He’s a fighter. He’s special in so many ways. Others didn’t see it that way. All they saw was a boy with a left eye that was completely skinned over and a right eye that barely looked like it was functional. School administrators refused to accept him into regular elementary school, fearing the reactions of other students. Instead they sent him to a “retarded and blind” school. In doing so, he was denied an education matched to his very capable abilities.
giving back
©ALO Cultural Foundation
The Starkey Hearing Foundation has given away nearly 500,000 hearing aids worldwide since the year 2000. Seeing the heartwarming photos of the children receiving their new hearing aids is always a pleasure. What we don’t often see is the tremendous impact that the hearing aids make on the lives of the recipients. In this issue, we will feature a follow-up story on Hussein, a child with Fraser’s Syndrome who lives in Beirut.
Hussein was referred to the Foundation by the House Ear Clinic in Los Angeles after the ALO Cultural Foundation® secured treatment and diagnosis. Fraser’s Syndrome includes visual deficits, hearing loss, webbed fingers and toes and other anomalies. Many of these children do not survive, or are left without proper education because of the wide range of disabilities they face. Hussein was fortunate enough to have a family who wouldn’t give up on him and people at the
ALO Cultural Foundation who led the advocacy to teach him to read, write and speak English along with his native Arabic. Because of the difficulty that Hussein has with the shape of his ears, and limited dexterity, hearing aids with #13 tubing earmolds and traditional controls are cumbersome and very difficult for him to adjust. Custom 50-gain receiver molds were designed at the Center for Excellence in Minneapolis, and were fitted at the Beverly Hills office of the Starkey Hearing Foundation by Trevi Sawalich and Dennis Van Vliet in 2009. Hussein adapted very well to insertion, removal and adjustment of the RIC devices and returned home to Beirut hearing very well. International Business Sales Manager Giscard Bechara checked up on Hussein while traveling in Beirut in the fall of 2010. While he found that the hearing aids needed primarily routine cleaning, he took new impressions and asked that new custom receiver molds be built
I was honored to meet this amazing child who exhibits such a passion for learning and life.
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Right: Giscard with Hussein after his fitting.
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The Starkey Hearing Foundation is striving to change the social consciousness of hearing and hearing loss prevention. Hearing loss affects one in 10 Americans, and 63 million children worldwide, yet many do not have access to the hearing devices that can help correct that disability. Each year, the Foundation delivers more than 100,000 hearing aids through hearing missions in countries stretching from the U.S. to Vietnam. Since 2000, the Foundation has supplied nearly 500,000 hearing aids to people in need, and is striving to achieve its goal of distributing over one million free hearing aids in this decade. In addition to giving the gift of hearing, the Foundation partners with Best Buy® and the Grammy Foundation® to promote ‘safe hearing’ and hearing loss prevention among teens and young people, through its national program, SoundMatters™. For more information on the Starkey Hearing Foundation, visit www.starkeyhearingfoundation.org.
to ensure that Hussein would receive optimum performance from the hearing aids. The new receivers were rushed back to Beirut and Giscard was able to fit them before he returned to the U.S. Bechara reported, “I was honored to meet this amazing child who exhibits such a passion for learning and life.”
Help Us
Help You
Hussein isn’t your typical child; he’s a survivor. He’s a fighter.
It was predicted that Hussein would die soon after birth. He had severe intestinal malformations that prevented the most basic of vital functions. He endured and survived because his mother never stopped fighting for his chance to live normally, and because those who have met Hussein can see his potential. His mother was promised that the ALO Cultural Foundation would work to find a miracle for him. Organizations such as Unique Image, Inc. in California and the Starkey Hearing Foundation have stepped up to play a part in delivering that promise. Starkey and ALO Cultural Foundation will continue collaboration to ensure Hussein receives long-term hearing aid support. Hussein wanted to make sure that we know that he is doing very well in his studies, and appreciates the help that has been provided.
Manufacturing custom hearing aids, molds and
• Complete audiogram including MCL/UCL data
receivers is best accomplished as a partnership
• Use the order form that corresponds to the product ordered
between the clinician and the manufacturing team. Art and skill are combined with good knowledge of the ultimate beneficiary: the patient. The following tips are intended to help you bring your extensive knowledge of the patient into the process.
• Mark the outside of the box appropriately for routing purposes • Patient Age • Skin Tone • Special Considerations (dexterity, previous hearing aid wearer, surgical ear, etc.)
Tip One: Orders Did you know that you can order products directly through the Inspire® software? Our innovative electronic order form can be a time-saving option for your business. Inspire-driven order forms are processed more efficiently, accurately and with less design rework! In fact, nearly 100% of Inspire order forms do not require design rework, which means quicker turnaround for you and your patient. If you prefer written order forms, here are some key points to include to help us process your orders without clarification or delay: • Bill to and Ship to Account Numbers • Address of each location • Contact Information
Best Buy, the Best Buy logo, the tag design and BestBuy.com are trademarks of BBY solutions, Inc.
• One order per box
• Phone Number
Tip Two: Same-Day or One-Day Service Want Same-Day Service or One-Day Service? Here are a few tips to help ensure your order is processed on time: • Write Same-Day or One-Day on the outside of your FedEx Bag (this will allow us to flag your order immediately upon receipt). • Identify Same-Day or One-Day on the Impression Box (this will allow us to flag your order immediately upon opening of your FedEx Bag). • Mark Same-Day or One-Day on your Paperwork (this will allow us to flag your order immediately upon design and entry).
Sounding Board
About the Starkey Hearing Foundation
GRAMMY Foundation is a trademark of National Academy of Recording Arts & Sciences, Inc.
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29
Close-UP STAFF SPOTLIGHT: JOYCE ROSENTHAL
EMPLOYEE PROFILE
What is your background?
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My education is in Audiology and Electrical Engineering. I earned a master’s degree in audiology (they didn’t have Au.D. programs back then!), and a second bachelor’s degree in electrical engineering. All my professional experiences since then have been hearing related in one way or another. I worked as a researcher in a speech acoustics laboratory and as a programmer on software for conducting psychoacoustic experiments. I even did another stint in school as a doctoral student at MIT. I left the program before finishing my dissertation, but the experience was still valuable. Among other things, I performed cochlear implant experiments on rats, observed ear surgeries (on people), and worked in the audiology clinic at the Massachusetts Eye and Ear Infirmary.
How did you start in the hearing aid industry? I was always curious about hearing, having grown up with a close friend who was deaf. I knew before I finished my audiology degree that I didn’t want to do clinical work, but I was still very interested in electroacoustics and hearing aids. There was an acoustics course I wanted to take, but I couldn’t enroll until I completed all the prerequisites. That’s when I started taking undergraduate courses again, which led to the
second bachelor’s degree. I took a few detours along the way, but I knew that I wanted to end up working at a hearing aid company. I moved from Boston, Massachusetts to Minnesota in June 2001 to work at Starkey.
What is your role at Starkey? I am a Senior Development Engineer in Product Management. My responsibilities have always included a mix of product development tasks (writing requirements and testing), continuation engineering (continue to improve released products), and internal support/training. As the technical lead of an interdisciplinary team called ”Fitting Systems,” I focus on areas related to how the hearing aid response is predicted and displayed in our fitting software, prescriptive fitting formulae, and hearing aid-integrated real-ear measurement systems.
Tell me about a memorable experience or achievement in your career at Starkey. In 2003, I attended my first Gala for the Starkey Hearing Foundation. One of the items up for sale at the live auction was a collection of autographed Robert De Niro movie posters. My cousin happens to work with De Niro, but I hadn’t spoken to her in years. I don’t know what I was thinking, but I guess I was so caught up in the excitement of the
Gala that when I saw those posters, I jumped out of my seat and ran over to Bill Austin to tell him that I might be able to throw in lunch with Robert De Niro. He couldn’t hear me and had no idea why I was bugging him during this live event, so I shouted a little louder “I might be able to arrange for the highest bidder to have lunch with Robert De Niro.” Bill still couldn’t hear me in all the noise, so I shortened the message and said it louder – “I CAN ARRANGE LUNCH WITH ROBERT DE NIRO!” Before I knew it, Bill was whispering something to the auctioneer, who then blurted out “includes lunch with Robert De Niro,” and the bid jumped up by $7,000! The next day, I emailed the news to my cousin. She replied to me in giant font with one word – “OY!” After one long year, my cousin came through. The buyer was invited to be on location in New York at the closed set filming of a movie directed by none other than Robert De Niro!
What is the most interesting and/or exciting part of your job? My most satisfying experiences have been working on both the ”Integrated Real Ear” and ”Live Real Ear” applications in Inspire®. I enjoy these types of projects where I’m involved in all phases of the development process from concept to release.
Any challenges you face in your position? Setting priorities and rearranging them on the fly is always a challenge. The Fitting Systems team has lots of ideas for improvements to hearing aids and software, but the order in which they are implemented has to be tied to customer benefit. I use the data available to me from Customer Service, Education and Training, Sales, and Quality to gauge the relevance of proposed improvements, and to look for trends that might indicate the need for other critical improvements. I also make extensive use of our Data Warehouse tool, which allows me to analyze gain settings, feature settings, and real-ear measurements from thousands of hearing aids.
Joyce Rosenthal, Senior Development Engineer, Starkey Laboratories, Inc.
What do you do for fun outside of work? Nothing too unusual…I enjoy spending time with friends, going to movies, eating out, working out, photography, and making jewelry. I mentor a wonderful teenage girl who I try to see at least twice a week. I spend most of my vacations visiting family in Massachusetts. I love Minnesota, but I really miss the ocean!
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IIC
Invisible-In-The-Canal Hearing Aids
technology spotlight
A Completely-In-The-Canal (CIC) hearing
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aid can be defined by the location of the faceplate, 1-2 mm inside the aperture of the ear canal (Gudmundsen, 1994). For years the CIC has been the benchmark for small, near-invisible hearing aids. Publications have documented the benefits of CIC fittings, including decreased occlusion (Mueller, 1994),
Dennis Van Vliet, Au.D. & Jason A. Galster, Ph.D.
Advances in digital modeling, laser-shell fabrication and modern microchip packaging techniques have resulted in hearing aids that are smaller and more powerful than those of the past. Today, custom hearing aids that fit deeply into the ear canal can be built on a routine basis. In fact, hearing aids can now be built to fit past the second bend of the ear canal, allowing the faceplate to be seated deeply in the ear, providing an invisible hearing aid fitting. The performance and cosmetic advantages of this fitting style appeal to a wide variety of hearing aid candidates, many of whom may not consider more visible hearing aid options.
A New Category of Hearing Aid
The performance and cosmetic advantages of this fitting style appeal to a wide variety of hearing aid candidates.
The convergence of hearing-related technologies allows the CIC to be made smaller than ever; small enough that they can be fit past the second bend of the ear canal. These deeply inserted hearing aids are effectively invisible to others (Figure 1). When the hearing aid is fit to the second bend of the ear canal, it may be considered an InvisibleIn-The-Canal, or IIC, a new category with respect to size and position of the device. An IIC hearing aid is one in which the faceplate is at or near the second bend of the ear canal, and the medial aspect of the shell is much closer to the eardrum. The deeper position of the hearing aid allows for several technical advantages.
increased satisfaction (Ebinger, Mueller, Holland & Holland, 1994), decreased amplification of wind noise (Fortune & Preves, 1994), and improved localization when compared to Behind-The-Ear (BTE) fittings (Best, Kalluri, McLachlan, Valentine, Edwards & Carlile, 2010). All of these benefits were realized as a result of the fitting style.
Figure 1. The left panel shows a traditional CIC hearing aid fitting that terminates at the aperture of the ear canal. The right panel shows the position of the IIC, fit to the second bend of the same ear canal.
33
Acoustic Benefits of Canal Hearing Aid Fitting
The reduced residual ear canal volume associated with an IIC fitting also affects the sound pressure level at the eardrum, effectively increasing the overall efficiency of the hearing aid. As illustrated in Figure 3, Boyle’s Law states that, as volume decreases, pressure increases. Thus, a smaller volume between the end of the hearing aid and the tympanic membrane yields a greater sound pressure level for equal receiver output.
Volume V
The ear canal and pinna filter the natural spectrum of sound before it reaches the eardrum. Microphone placement on BTE hearing aids reduces some of these beneficial effects. The loss of these acoustic cues results in degradation of the wearer’s ability to localize sounds. Data collected at Starkey Laboratories, Inc., suggests that canal placement of the hearing aid microphone retains some aspects of the ears’ natural filtering as compared to the microphone placement of a BTE style hearing aid. Figure 2 shows three measurements of directivity index (ANSI S3.35, 2004): an open or unaided ear, an IIC hearing aid, and a BTE hearing aid. Compared to the open ear, the BTE hearing aid fitting reduces
directivity. Measures from the IIC hearing aid were similar to the open ear. Data such as these support the expectation that canal placement of the microphone, as provided by the IIC hearing aid, will allow for improved localization ability when compared to a BTE hearing aid fitting (Best et al., 2010).
Pressure P
IIC
BTE
3D depiction of where an IIC sits in the ear canal.
Summary Impressions for the IIC The key to an accurate and comfortable fit with IIC hearing aids is an ear impression that extends 10-12 mm beyond the second bend. A good understanding of the anatomy and physiology of the ear canal along with deliberate technique make it possible to safely and easily obtain the impressions necessary for building IIC hearing aids. No special equipment is necessary for IIC impressions. However, instrumentation to illuminate and view the ear canal beyond the second bend is valuable. Silicone impressions taken with a high flow, low viscosity material will typically fill the entire canal accurately and completely.
Pressure P
Unaided
10000
) B d ( x e d n I y t i v i t c er i D
-4 -2 0
4
References ANSI (2004). ANSI S3.35-2004 “Method of measurement of performance characteristics of hearing aids under simulated real-ear working conditions” (American National Standards Institute, New York).
Ebinger, K.A., Mueller, G.H., Holland, S.A., & Holland, J.W. (1994). Assessing the speech-understanding benefit from CIC hearing aids. The Hearing Journal, 47(11), 35-42. Fortune, T., & Preves, D. (1994). Effects of CIC, ITC and ITE microphone placement on the amplification of wind noise. The Hearing Journal, 47(11), 23-27.
2
6
34
Figure 3. Illustration of Boyle’s law. When referenced to the ear canal, decreasing residual ear canal volume results in greater hearing aid output. V e m u l oV
1000
Modern hearing aid processing and laser shell fabrication have made the creation of small, deep-fitting hearing aids a possibility. Existing worries of feedback have been addressed with feedback cancellation and the patient’s experience is being improved by advanced noise reduction technologies. The end result is a highlyfeatured, premium hearing aid that is invisible when worn, and meets the needs of the most discriminating patient.
Best, V., Kalluri, S., McLachlan, S., Valentine, S., Edwards, B., & Carlile, S. (2010). A comparison of CIC and BTE hearing aids for three-dimensional localization of speech. International Journal of Audiology, Early Online, 1-10.
Frequency (Hz) 100
Figure 2. KEMAR based measurements of directivity -8 index using an open ear canal, Invisible-In-The-Canal -6 hearing aid and a Behind-The-Ear hearing aid are shown.
After taking a careful patient history and observing clinically appropriate safety precautions, a flattened oto-dam is placed deep in the canal, very near to the tympanic membrane. Lubrication of the oto-dam with Oto-Ease or a similar agent will improve comfort while placing the oto-dam and ease release of the silicone impression from the ear. Starkey has developed a vented cotton oto-dam that can be used to equalize pressure during the removal of the cured impression, shown in Figure 4. With proper counseling, the patient experience during impression taking and removal is very similar to standard impressions.
Figure 4. Two specially designed oto-dams are shown. A small tube allows for equalization of pressure while taking the earmold impression.
Gudmundsen, G. (1994). Fitting CIC Hearing Aids—Some Practical Pointers. The Hearing Journal, 47(11), 10, 45-48. Mueller, G.H. (1994). CIC hearing aids: What is their impact on the occlusion effect. The Hearing Journal, 47(11), 29-35.
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Continuing
Education tips & tools
Practice owners and clinicans working in a successful practice know that the job requires hard work, business acumen and the desire to continue
Tip #2 Benefits of Speech Mapping
to learn and grow as professionals. Starkey offers
The Speech Mapping feature in Inspire can be a great fitting and counseling tool. It shows the hearing aid response to live real-world inputs – an important thing for patients who just want to understand how the sounds they want to hear – like music and speech – will sound with the hearing aids. For fitting, you can match hearing aid gain or output to a prescriptive target, monitor changes in fitting adjustment and the behavior of adaptive algorithms, and evaluate comfort of speech and other sounds. As a counseling tool, Speech Mapping provides flexibility with a variety of hearing aid response capture options as well as
a number of opportunities for continuing education. Following are frequently requested fitting tips as
learning Corner
well as best clinical practice tips. Visit Starkey’s
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Clinicians may select or deselect Auto Path steps as desired before launching the routine.
Web Channel on Audiology Online for a complete list of classes that can be taken for continuing education credits.
Fitting tips
In hearing healthcare practices, extreme measures are generally not necessary. However, it is smart to know the basics.
Tip #3: Programming SoundLens
The modes of microbe transmission include:
When programming SoundLens™, be sure to use the specially designed programming strips, which attach to the programming cables used for all S Series™ iQ products. Collar clips may be helpful if the programming cables are pulling the hearing aids out of position in the ear canals. When programming: • Open Inspire. • Insert the programming strips. • Select Auto Path to mute the hearing aids. • Insert the hearing aid into the patient’s ear. • Select Quick Connect from the Get Started screen. Do not select Best Fit for 2010 IIC hearing aids. They were modeled as CICs in the software and most patients find the actual match to target too strong. The 2011 SoundLens products are properly modeled in the software as IIC II (second bend), IIC I (first bend), or IIC a (aperture) hearing aids and may be best fit as needed.
Clinical Best Practice Infection Control Infection control is an ongoing and evolving topic in healthcare. This is an area that cannot be forgotten in the hearing aid dispensing practice. It is important for the hearing professional to have basic knowledge of disease transmission, universal precautions and Occupational Safety & Health Administration (OSHA) guidelines.
Tip #1 Using Auto Path Auto Path is the automated fitting wizard in Inspire® that allows you to facilitate a quick and easy initial fitting. Think of it as your automatic checklist to facilitate your initial fitting. The steps available in the sequence are based on the technology level of the connected hearing aids, making it easy to get started. Orange icons represent steps that will be completed as part of the Auto Path routine, while gray icons are steps that will not be completed.
different display and viewing options. And, the live input option gives you the power to engage patients and their families more fully in the fitting process.
Live Speech Mapping shown in 3D from Inspire 2011
Infection control is the “conscious management of the clinical environment for purposes of minimizing or eliminating the potential spread of disease” (Bankaitis & Kemp, 2003, 2004).
•V ehicle: Disease is spread through contaminated food, water or bodily substances irborne: Disease is spread via water •A droplets or particles by such activities as sneezing or coughing •V ectorborne: Pathogens spread by insects or animals In a hearing healthcare practice, cerumen, or ear wax, is commonly encountered and is generally not an infectious agent unless it is contaminated with mucous or blood. A simple visual inspection is not enough to determine that, so offices should follow the universal guidelines established by the Centers for Disease Control (CDC): •W ear gloves and masks when there is potential for contact with bodily substances. •W ash hands: Before seeing the patient, after seeing the patient, after removing gloves and any other time it is deemed necessary. •C lean and disinfect surfaces using an EPAapproved hospital-grade disinfectant. • Sterilize critical instruments. •D ispose of waste properly. Cerumen may be disposed of in regular trash, but if blood is present, then waste should be in a separate container and marked. Additional best practices to help keep you and your employees healthy: • Clean tools and earphones after each use. •U se a storage device to accept hearing aids from a patient and carry them around the office. •U se personal protective equipment when handling or modifying hearing aids or taking impressions.
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Tools andresources Find the answers on StarkeyPro.com
Find all of the answers to your questions and the information you need on the new and improved StarkeyPro.com – 24/7. It’s easier than a one-click order!
Tools and Resources Include: • More intuitive navigation and structure •E asier access to all of the information you need in 1-2 clicks •N ew, broader dropdown menus in each section, giving you instant access to everything you need in a single click • The latest news from Starkey And, more content is now available outside of the password-protected area including: •C ustom and standard product features and specifications • Earmold product line and catalog • Downloadable order forms • Operations manuals • Battery information • SoundChoice information • Starkey evidence and research information
Don’t have a username and password? Click on My Account in the main navigation. A box will appear; you will have the option to click “Don’t have a Starkey account? Enroll now.” It only takes a couple of minutes to sign up and fewer than 24 hours to receive your registration information, giving you access to more specific, in-depth information on particular orders and a variety of forms and downloads. Still can’t find what you are looking for? StarkeyPro is a constantly evolving resource. Please let your Starkey Representative know if there’s something you would like to see on the site.
A variety of information still exists in the password-protected area as well, including:
Have you ever found yourself in this situation: a patient is sitting in your office and wants to purchase a custom hearing aid, but you can’t find an order form? Or, you want to get specifics about a product, but you don’t know how to find that information?
• Repair forms • Warranty card request form • Hearing aid warranty renewals • Checking warranty status • Registering standard products • Printing FedEx labels • Tracking in-house orders and repairs • Linking to your Marketing On Demand™ account
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&
NEWS VIEWS Starkey Introduces AMP
AMP™ is the hearing aid for people who are not ready to wear a hearing aid. It addresses the concerns of patients who are reluctant to consider hearing aids because they do not want to be seen wearing one, have outdated perceptions of how they sound or are concerned about the cost. Additionally, AMP’s programming method makes fitting efficient so that patients can walk out the door wearing an AMP in a single visit. AMP can also turn up the volume on your practice! In test markets, AMP advertising performed as well as our most successful marketing campaigns, with 70% of respondents being potential first-time wearers.
STARKEY NEWS
Wi Series Options Expanded Wi Series™ with IRIS™ Technology lives up to the promise of wireless by eliminating the need for body-worn devices and pairing during programming and daily listening. Wi Series is an option for more patients than ever with two additional technology levels – the Wi Series i90 and Wi Series i70.
SoundLens – Now with Voice iQ2 Starkey’s SoundLens™ is the invisible-in-the-canal (IIC) hearing aid with Voice iQ2, which is designed to nearly double Starkey’s already leading noise reduction while still preserving speech. The invisible-in-the-canal style has become one of the most requested products available due to its invisibility in most ears and the ability to insert and remove it to promote better ear health.
Starkey Wins Awards Starkey continues to win awards around the world for its innovative products. Most recently: was honored with an IF product design • AMP award, a German design award, which this year had winners selected from more than 40 countries. • SoundLens is the recipient of a number of honorsincluding includingaared reddot dot award: product honors award: product design, a European competition which design, a European competition in in which approximately1,700 1,700companies companiesform form 60 approximately countries submitted more than 4,400 entries; 60 countries submitted more than 4,400 a Consumer Electronics Show 2010 entries; a Consumer Electronics Show 2010 Innovations Honoree designation; and Innovations Honoree designation; and finalist finalistforstatus for theEdison 2011Best Edison New status the 2011 New Best Product Product Awards. Awards.
Apps Make Your Life Easier SoundCheck is the latest in the family of apps from Starkey for iPods and iPads to give hearing professionals more counseling and fitting options – and new ways to interact. SoundCheck is a hearing screener application that allows patients to quickly evaluate their own hearing to determine if it is within a normal range or if they potentially have hearing loss. The app includes easy-tounderstand results, learning materials and links, and an automatic hearing professional locator. Starkey has a variety of other apps that highlight Starkey’s technology, like S Series™ iQ, or provide patient counseling tools, such as SoundPoint and Hearing Loss Simulator.
Keep up with Starkey’s latest news at StarkeyPro.com 40
VOLUME 1 | ISSUE 1 | 2011
POWER
comes in SMALL PACKAGES One California audiologist discovers less is more
Starkey Audiology Series Improved Patient Satisfaction in Hearing Aid Fittings
Answers from an Expert
PREMIERE
ISS UE !
Q&A Session with Catherine Palmer, Ph.D.