An American Treks Down Under, Pioneers Blended Service Model



Author: Ryan O’Clair, Au.D. and Brian Taylor, Au.D.

One of the benefits of traveling outside the United States to give lectures is the opportunity to meet thought-provoking clinicians. Ryan O’Clair, a young American audiologist living in Brisbane is no exception. I met Ryan last May at the Australian College of Audiology (ACAud) National Congress meeting.

Ryan is full of enthusiasm for audiology, and it just so happens that he stands at the vanguard of innovative service delivery methods. He practices at Blamey Saunders Hears, a chain of retail locations scattered throughout Australia that blend on-line service delivery with traditional brick and mortar clinics. Given its geographic expanse and relatively sparse population, Australia is probably the ideal place to launch this blended approach to hearing care. But as a growing number of people receive healthcare services via the internet, this market is expected to grow in the U.S. If you’re an American audiologist, there’s a good chance that soon you’ll be orchestrating a substantial amount of patient care remotely, using some combination of the World Wide Web, Wi-Fi and smartphone-enabled apps. Ryan’s experience indicates that many patients, to use his phrase, like to receive their hearing care in more than one lane. To learn more about these lanes, you can read below.

Over a pint of Australian Pale Ale at Ryan’s favorite microbrewery in New South Wales, called the Grifter Brewing Company, I recorded this interview with him.

BT: Hi Ryan. Tell us about yourself.

RO: Sure! I was born in Iowa, raised in Colorado, and went to college in Oregon. My clinical doctorate degree (AuD) is from Pacific University, near Portland OR. I’ve been in Australia for 3-plus years practicing audiology.  I love audiology, I love sound, and the Australian birdsong down under is unreal.

BT: How did you end up practicing in Brisbane?

RO: Throughout graduate school at Pacific University, Australia was continually referenced for its advancements in audiology and hearing health care. With the National Acoustic Laboratory, the Australia Hearing Hub, the invention of the cochlear implant, and all of the outstanding research coming out of the University of Queensland (UQ), Australia was frequently mentioned in some way or another in the classroom. If you stop and think about it, there’s a lot of useful audiology research that pours out of this country.

Although I’d found an outstanding gig in the US at a world-class audiology practice in the states, opportunities for recently minted audiologists are pretty expansive, The allure of adventures internationally began to develop.

I found a mysterious job post for clinical work with opportunities for community education, and research and development, located in the heart of the Sydney’s central business district (within walking distance from the Sydney Opera house). Simultaneously, while considering this position, a lecture by Dr Frank Lin piqued my interest. His lecture outlined his concerns for individuals with hearing loss and how the current field of audiology needs to re-focus its efforts to better meet the needs of many adults with age-related hearing loss.

Be it kismet or coincidence the more I learned about this Australian hearing aid company, the more I realized they had created solutions to the exact challenge’s Dr Frank Lin had shared.

I accepted the job offer, made the leap, crossed the ocean to Sydney Australia where I lived for a year and a half. Then, I moved north to warmer beaches, and opened the Brisbane branch of Blamey Saunders Hears, a stone’s throw from UQ. This August, we celebrated our 2-year anniversary of the Brisbane clinic’s opening.

BT: You mentioned your practice, Blamey Saunders Hears. Tell us more about them and your role within the organization.

RO: Blamey Saunders Hears (BSH) is an Australian hearing aid company and is leading the way in teleaudiology. The two founders of BSH, Professor Peter Blamey and Dr Elaine Saunders worked with Cochlear Corporation for roughly 15 years and developed several patents and technology.

Motivated by a profit-for-purpose mentality they marketed their inventions (sound algorithms found in hearing aids, telephones and headsets) and attracted a team of like-minded audiologists and engineers. Ultimately, they created their own hearing aid company.

Geographically, Australia is parallel in size to the USA, with substantially less population by comparison. As you’d imagine with a country of this geographic expanse, there are areas without access to hearing aid services.

By creating their own teleaudiology company, BSH’s range of services is considerable. Well, it’s essentially unlimited, as long as an individual has access to a phone or internet provider (as a reference point, we have clients who live on islands off the coast of Madagascar).

The overall philosophy and commitment of the company is to create innovations by breaking down barriers to hearing healthcare. Primarily through affordability, accessibility, and technology (very similar to what Dr Lin’s lecture said needs to change). For my role in the organization, I function as a clinical audiologist and help people in a traditional clinic, online, and I also travel to remote locations.

BT: Describe the on-line hearing test and your triaging process?

RO: From a clinician’s perspective, one of the most striking things that BSH has created is the Speech Perception Test (in-house we call it the SPT).

The SPT is a clinically validated hearing test that uses words instead of pure tones. It’s more than just speech audiometry or a counselling tool. It’s a hearing test and it is also how we fit our hearing aids (our devices are digitally programmed via words instead of the pure tones from an audiogram).

As the SPT hearing test is using words at a conversation level, instead of looking for the softest audible thresholds, there are considerable advantages to this approach. For example, the test can be conducted remotely as it is not looking for thresholds, but speech comprehension. Interestingly, the test is determining not only how individuals hear the parts of speech, but also how they mishear words.

The test is comprised of 50 consonant-vowel-consonant words of some 30+ randomized word lists. And the test is regularly conducted in our clinics and online.

You asked how we triage. The results of the word test (the SPT) are an aspect of how we direct clients through our channels of communication.

While the SPT is not a pure tone threshold, expressed an audiogram, the SPT result and the pure tone threshold do visually parallel one another (e.g. low frequency and high frequency, vowels and consonants). The SPT result corresponds to pure tone thresholds. For example, a moderate-severe audiogram results in a poor SPT score and a milder loss on the audiogram usually corresponds to a better SPT score.

Like many speech-in-noise tests, used clinically, the SPT is both a difficult and fascinating test. It’s one of the things that really caught my eye when I joined the team. I encourage other audiologists to check it out online.

BT: That’s interesting. I am curious about more traditional types of audiometric tests you may conduct. What speech in noise tests do you use and how do you apply a patient’s score to the hearing aid selection process?

RO: In our traditional clinics we have an Australian version of the QuickSIN. It’s effectively parallel to the QuickSIN used in North America with the same kind of sentence structure, except it’s sporting the Aussie accent.

From BSH’s perspective, we’re encouraged to counsel beyond the audiogram. As a crew we’re mindful that individuals hearing ‘within normal limits’ on the audiogram may still have considerable difficulty processing speech or hearing when background noise is present.

As an aside and anecdotal story that I’m quite fond of hones in on the company’s perspective…

Professor Blamey and Dr Saunders once put on an impromptu skit they created at a local audiology workshop. Dr Saunders played the role of “Travel Agent” and Professor Blamey played the role of “Overworked Businessman” looking for a vacation.

Overworked Businessman arrived and communicated to the Travel Agent, “I’m overworked and I would like a vacation” to which the Travel Agent replied, “I don’t know if you need a vacation just yet-- we’re gonna do a series of tests to verify this first.”

The Agent puts the Businessman through all sorts of challenging tests, measurements, bar graphs, finally replying, ‘I’ve decided you could use a vacation.’

BT: Let’s talk more about Blamey Saunders Hears’ blended approach to care. Could you describe your blended approach?

RO: I’d love to explain it. In the blended model, we will help individuals with hearing loss in whatever mode they desire to receive care. That means we help people directly online (remote care), we help people in a more of a traditional clinic (face-to-face), and we help people in temporary clinics, too. Let me explain what I mean by a temporary clinic.

Our team travels quite a bit creating mini pop-up clinics we call Link clinics. We’ll book out a particular location (in a library, or local community center), and any individual in the area that would benefit from our help will make an appointment and see us on that day.

Now what’s interesting about the whole blended model is that individuals go between lanes. Meaning a person may purchase online, have difficulty at some point and then come directly to the clinic. Or vice versa. Someone is outside of the normal service area, may come to the clinic initially for the face-to-face approach then transition to more of an online role for support. And, when needed, they can see us again at a local pop-up clinic.

Our clients (patients) are continually going back and forth in the blended model, it’s not one pathway. As an example, I’ve seen the same individual in Sydney, Brisbane, and Surfer’s Paradise. The blended model gives patients more choices on how they want service delivered to them.

A blended model means that the company is readily available to be in different places, depending on the individuals who are requesting services. And that’s one of the strengths of the model, is that we can help people wherever they are located or how they want to be helped.

BT: What are some of the key factors that tell you a patient/client needs a face-to-fact visit with an audiologist?

RO: Well it’s a method of triaging in which we start with an intake form that’s comparable to the CEDRA (Consumer Ear Disease Risk Assessment --a recently developed tool, using machine learning principles that allows consumers to ascertain their risk for ear disease). We conduct case histories, gauge levels of complexity of clients, and provide feedback on our concerns when needed.

In Australia, the healthcare appears to be quite accommodating, cost effective, and approachable. It makes triaging with medical professionals fairly easy from my experience, even when requesting additional otoscopy in a remote location prior to updating a clinical appointment.

Also, the Speech Perception Test has its own approach to triaging. If individuals fall outside of a degree of range (e.g. someone who has severe to profound hearing loss), additional information will be required.

The biggest determining factor, for a requirement for a face-to-face appointment, is usually the clients themselves making the request. While they are aware that a lot of help can be conducted remotely, many still prefer to meet with an individual face-to-face.

BT: In contrast, what is the typical profile of a patient/client that could purchase hearing devices on-line without a face-to-face visit with an audiologist?

RO: Behind the scenes of the company there’s a great deal of effort to make things as effortless as possible for the client. The whole system is designed to be intuitive and easy to use, from the initial point of contact on our website, to the ongoing follow-up.

Experienced hearing aid users tend to be strong candidates for the blended model. From an experienced hearing aid wearer’s perspective, they know what to expect, they have insights, have already participated the clinical experience, so they’re usually better able to self-manage their condition. Experienced hearing aid wearers are, therefore, the primary examples of individuals who are great for receiving remote care, delivered on-line.

Additionally, stereotypically, engineers are drawn to on-line care. They’ve investigated the company, seen our accolades, and examined the device specifications. They tend to be bold and committed to this direction per their own decision.

Individuals who seek the freedom to self-direct their care are drawn to this concept as well. We refer to these kinds of clients as Do-It-Yourselfers. They’re the clients who scour the internet for a pair of cables and a HiPRO box. They’re the individuals at a hearing aid fitting who communicate, “I wish I had this software at home.”

Finally, family members of first-time hearing aid users are also good candidates to receive remote care via the web. It’s an opportunity to purchase the devices and receive care in a comfortable and non-confrontational manner.

Now, from my perspective, which may deviate from the company’s, individuals that purchase directly online tend to be well read and researched. In my experience, a lot of academics are drawn to our company due to our publications and awards.

BT: Describe the process for someone who does buy hearing devices online from you. Does that person have access to a clinic visit if needed?

RO: For BSH, there’s a continual level of communication between clients and the clinician. We’re constantly communicating directly via phone calls, online chats, e-mails, screen-shares, or our version of what’s effectively Google Hangouts/Skype/Facetime.

Purchasing online (via this model at least) doesn’t mean clients go without any form of follow-up or support. There’s a perception of online that means non-contact and that’s not the case at all. This isn’t a fit and forget model.

And because of the way that the model works, clients have access to more than one individual; a whole team of individuals with professional and academic backgrounds and skillsets are essentially on-call to help a person when or if they request it.

Now, for that moment when a remote appointment requires a face-to-face visit with an audiologist, that’s readily available, too. That’s why we travel and help people in our mini-clinics. Using me as an example, I live in Brisbane but I also regularly travel the Sunshine Coast and the Gold Coast. I travel from Noosa to Byron Bay and frequently visit Surfer’s Paradise.

Occasionally I head to drier climates a bit out west too. It’s a bit of an audiology adventure really.

BT: For those that buy online and do eventually need a visit with an audiologist, what are the most common problems they encounter and how do you address those problems?

RO: For the individuals that request a face-to-face appointment, it’s sometimes as simple as a physical fit issue. We do a lot of video work to help guide clients, but sometimes it’s merely an incorrectly twisted tube or wire that prompts an in-house appointment.

But the majority of the time, what individuals are really looking for is reassurance. It’s the confidence and the coaching. It’s the counselling. It’s the expertise.

They’re seeking the expert on hearing loss and hearing aids….and they want that human interaction that can only be delivered face-to-face.

BT: I’m guessing your hearing aid fitting and follow-up process might be different than what is done in the US. Please tell us about how you conduct a typical hearing aid fitting appointment and what you do during follow-up appointments for a new client over their first 6 months of hearing device use.

RO: The fitting and follow-up processes in Australia are pretty on par with the US. I’d say best practices are best practices regardless of where in the world you are located (at least from my experience being in US vs. Australia).

Follow-up is similar with the blended model, with the added caveat that clients can get additional access via remote support whenever needed.

Of note, and not to get too side-tracked, but an exceedingly unique aspect of BSH hearing aids is that we do not use Wide Dynamic Range Compression (WDRC) for our hearing aid fittings. It’s a completely different system and protocol called ADRO. ADRO (which stands for Adaptive Dynamic Range Optimization) is another one of many patents and inventions created by Professor Blamey. 

For research-minded folk, if you dig deep into the literature and the specifications of different types of technology (hearing aids, cochlear implants, headsets…), you may find ADRO (e.g. Plantronics). 

ADRO is a different fitting philosophy than WDRC with the primary goal of keeping sounds acoustically audible and comfortable at all times (a.k.a if sound is too loud, make it softer--if sound is too soft, make it louder).

In layman’s terms, and to create a helpful visual analog, ADRO ‘crops’ sound to the most important and pertinent parts of the soundscape around us. Meaning, it keeps the critical parts of the soundscape within a sweet spot at all times for the listener. 

While it isn’t a linear hearing aid, the sounds produced by the devices continue to maintain a linear relationship (a 1:1 ratio throughout). As opposed to compression (which we know distorts sound), the sounds produced by ADRO are more reflective as to what they actually are acoustically. This is partly why so many experienced hearing aid users are enamored with the sound of the BSH devices. 

BT: Thanks for the overview of ADRO, I know that’s been around a while, and it’s worth mentioning that ADRO processing is also used in the hearing aids dispensed in Sam’s Club and Wal-Mart through the Lucid Hearing chain. Let’s move back to how you deliver care. What are the client advantages of the blended model you use?

RO: With a blended model, there are so many routes and pathways that clients can follow, they essentially begin to carve out their own hearing healthcare journey. They’re not locked into one lane for support. They can e-mail, call, pop-by a brick and mortar clinic, schedule a virtual appointment, or meet us at a temporary clinic, depending on their own location and schedule.

They have access to support and the freedom to receive help however they so choose.

Also, because they’re communicating with us as a team, full of different personalities and skillsets, they get to hear reinforced messages in new ways. I’ve found that audiologists all have their own particular insights, stories, and scripts, and sometimes it can be helpful to hear similar messages with a new voice.

Plus, the concept that clients can receive support without even leaving their own home, is appealing. It creates a pretty relaxed environment for an appointment, when the client is able to sit in their living room or at the kitchen table, sometimes with a loved one as we go through the process of troubleshooting remotely.

BT: What are the clinician advantages of the blended model?

RO: Teleaudiology extends a clinician’s level of outreach. We’re no longer limited by location. If a client is motivated and the clinician is up for the adventure, then with technology, creativity, and patience, successful teleaudiology becomes a reality, no matter the distance.

Settings can be adjusted in real-time. Troubleshooting can occur instantly, and help can be provided wherever and whenever individuals are willing to meet.

BT: Anything else you’d like to share about your love of audiology?

RO: I love audiology! And teleaudiology. This is an exceedingly exciting time to be involved in the profession, for all the reasons we have been discussing.

I keep hearing the lyrics to Bob Marley’s Redemption Song: ‘Have no fear for atomic energy, none of them can-a stop-a the time’

Audiology is a technologically-driven field and there are real opportunities to create change in positive and meaningful ways.

We all got to pick our quests and I’m proud to be an audiologist.

Saving the world one ear at a time.    
Ryan O’Clair, Au.D. is a clinical audiologist at Blamey Saunders Hears, a chain of Australian hearing clinics. He can be reached at ryan.oclair@blameysaunders.com.au.