Considerations for Hearing Assistive and Access Technology



Author: Clifford A. Franklin, Ph.D., Laura Smith-Olinde, Ph.D., and Samuel R. Atcherson, Ph.D.

As audiologists, we should consider our patients’ listening environments, their communication needs and all available resources to facilitate better hearing. Everyone should have equal access to information, education, and the joys of a hearing world. Any device that helps to overcome hearing loss, whether it provides or enhances sound, or provides sound-based information via visual or tactile cues, can be considered hearing assistive technology. Although hearing aids and implantable devices do not fit neatly into this definition, they often complement hearing assistive devices and vice versa. Hearing access technology relates to the methods with which we use these devices to contribute to equal access and equal opportunity.
Needs Assessment
Use of the World Health Organization’s (WHO) biopsychosocial (bio–body; psycho–mind/disposition; social–physical and peopled environments) model is a productive approach to a needs assessment that includes assistive and access devices. Audiologists routinely gather information about the body, and to some extent, the patient’s physical and social environments. Less commonly explored are a patient’s mind/disposition such as mindset and coping styles.

It is also important to consider a patient’s communication partners and listening environments. Thinking about the basic principles of acoustics, the characteristics of speech, and how this information may apply to different listening environments can be beneficial. Are there issues with the distance between the speaker and your patient? Do potential reverberation and noise issues exist? With whom does your patient communicate? Are there visual issues, such as line-of-sight barriers or the speaker’s face being in a shadow? Pinpointing the spaces that are important to a patient can help the audiologist and patient determine the most appropriate assistive/access devices for him or her. Finding out what technologies the patient uses is also important. For example does she use only a landline phone, a Bluetooth-enabled cellphone, and/or computer programs such as Skype or Facetime? Knowing these specifics sets the stage for either tailoring the assistive/access devices to the patient’s comfort level or introducing newer technologies to provide better and/or easier access to communication.

We should not overlook our patient’s workplace environment and associated communication needs. One or several assistive devices may be needed for the workplace from a landline telephone amplifier to a Frequency Modulation (FM)/Digital Modulation (DM) soundfield or induction loop system in a conference room. If you cannot assess the workplace in person, have the patient bring photographs and/or sound recordings of problematic locations to decide on the most appropriate recommendations. One possible resource for providing these necessary devices may be your state’s Vocational Rehabilitation Services.

The WHO model includes “personal factors” such as coping style and degree of self-efficacy. Audiology research in this area is sparse but in the last 10-15 years Cox, Alexander and Gray (1999; 2005; 2007) and Laplante-Levesque, Hickson, and Worrall (2010; 2011; 2012; 2013) have shown that perceived degree of disability, locus of control, self-efficacy, coping style, personality and stages of change are important dimensions underlying our patients’ choices with regard to audiologic rehabilitation. To help the audiologist assess some of these dimensions clinically, one resource is the Ida Institute patient motivation tools of The Line, The Box, and The Circle. Visit that website for a more in-depth explanation and use of these tools.

Lastly, documenting the utility of rehabilitation is important for the patient, the audiologist, and third-party providers. Tools such as the Client Oriented Scale of Improvement (COSI) and the Abbreviated Profile of Hearing Aid Benefit (APHAB) are useful pre- and post-fitting instruments that can demonstrate efficacy and utility of rehabilitation efforts.
Hearing Aids & Implantable Devices
Many treat hearing aids and implantable devices as the last step in hearing assistive and access technology. This limited vision of available assistance is understandable, as these devices play a significant role in assisting those with hearing loss; however, they are only a starting point for many patients.

Recently, wireless communication between binaural hearing aids has resulted in “super” directional sensitivity. These super directional microphone arrays have already shown advanced directional effects with the potential for even more improvement (Beck, 2013). Siemens has applied the technology, once reserved for hearing aid styles large enough to facilitate multiple microphones, to completely-in-canal (CIC) and invisiblein- canal (IIC) hearing aids.

While directional and now super directional technology has improved the signal-to-noise (SNR) ratio for hearing aid wearers, background noise remains a chief complaint (Abrams and Kihm, 2015). With the use of remote microphones, such as Phonak’s Roger Pen, noise, distance, and reverberation issues between the speaker and the hearing aid wearer can be greatly reduced. Because the speaker’s voice does not have to travel through the air to the listener, the speech is not degraded and the signal-to-noise (SNR) ratio is considerably better than when using hearing aids alone.
Contemporary Wireless Hearing Technologies
Newer wireless assistive and access technologies have been added to the established technologies of frequency modulation, induction hearing loop, and infrared systems. The newer technologies might be confusing; yet, we should probably become familiar with technologies such as Bluetooth, Digital Enhanced Cordless Telecommunications (DECT), Global System for Mobile (GSM) Communications, and Near Field Magnetic Induction (NFMI). It is important to understand some of the strengths and weaknesses of these wireless communications methods to assess their usefulness as hearing assistive and access technologies.

It seems that everyone knows and uses Bluetooth; but, why? It has become popular due to its availability, low power consumption, and low cost. The transmission range for devices using Bluetooth is about 30 feet. A new version of Bluetooth, known as Bluetooth Smart, or Bluetooth Low Energy, uses less energy than the original and has found its way into hearing aids, eliminating the need for a streaming device (Bluetooth Basics: A look at the basics of Bluetooth Technology. (n.d.). ReSound and Starkey have developed products that do not need a streaming device.

The microwave technology Digital Enhanced Cordless Telecommunications (DECT) uses the 1.9 GHz band and allows hearing aid wearers to listen bilaterally to landline phones instead of listening with only one hearing aid. Using a base station, the signal range is almost 2000 feet. Like Bluetooth, a low energy version of DECT, known as DECT ultra low energy (ULE) is now available (DECT—Worldwide Technology for Voice and Data Application, n.d.). One example of implementation of this technology is Phonak’s Dect phone.

With smart phones becoming more entwined with hearing aids, we should become somewhat familiar with Global System for Mobile (GSM) technology. GSM allows devices, such as cellphones, to communicate via networks. Networks range from large networks (macro cells), needing the large antennas we see on tall buildings or hilltops, to small networks (femto cells), which are typically designed for residential use.

Lastly, Near Field Magnetic Induction (NFMI) is a wireless technology similar to the familiar induction loop-telecoil. Unlike the previously mentioned technologies, it quickly loses signal strength as the transmitter and receiver move away from one another (Galster, 2010). So, the effective range for NFMI is about 6 feet, shorter than that of Bluetooth; but, it allows for hearing aids to communicate with one another and supports super directional microphone arrays.
Telecommunications Access
Speech-Based Telecommunications
All phones, landline and cell, are covered by the Hearing Aid Compatibility Act (HAC) of 1988 and must meet coupling requirements. To achieve optimal acoustic coupling, the phone speaker must be held as closely as possible to the hearing aid microphone, no matter the microphone’s location. One potential downside of acoustic coupling is that hearing aids may begin to feedback when a phone is placed next to them. Inductive coupling, through a telecoil, may need to be added to the hearing aid or implant. If the microphone is purposely deactivated when the telecoil is turned on, the signal has no interference from environmental sounds. Telecoils can be used with certain personal and public assistive listening devices (ALDs), including inductive loop systems. Telecoils are susceptible to interference from fluorescent lights, computer monitors, theft protection systems, and even the backlight of the cellphone. Such interference can often be overcome by simply moving to a different location. We should verify telecoils using a hearing aid test box.

Microphones and telecoils are rated M1-M4 and T1-T4, respectively. M1/T1 indicate greatest interference (least compatible with other devices) and M4/T4 least interference (most compatible). Cellphone ratings of 3 or 4 provide the most satisfactory service. Examples available with these ratings include the Samsung Galaxy S5 (M4/T4) and the Apple iPhone 6 (M3/T4). Encourage patients to ask the cellphone representative questions about cellphone/hearing aid compatibility and to try various cellphones in conjunction with their hearing aids before buying. There are two websites available to pre-screen for hearing aid compatibility with cellphones, www.phonescoop.com and www.accesswireless.org.

Some newer hearing aids are equipped with a wireless receiver for cellphones, mp3 players, computers and tablets. Synchronizing the aids to the devices allows wireless/hands free transmission of the audio signal directly to the hearing aids. As previously mentioned, some hearing aid manufacturers have developed products which do not require a streaming device.

The teletypewriter (TTY), a text-based telephone also called a Telecommunication Device for the Deaf (TDD) has been available for many years. Cellphones can be used with TTY/ TDD technology by patching an acoustic audio adapter into the cellphone headphone jack. The TTY/TDD instruments are often used in conjunction with the Telecommunications Relay Service (TRS). The Relay Service (dial 711) provides an operator to facilitate communication between the TTY/TDD user and the hearing person, reading the TTY information and typing in the spoken information.

Visual-Based Telecommunications
A Voice-Carry Over (VCO) phone is a hybrid between TTY and regular phone calls and can be used by individuals with speech that is well understood by others, but cannot always understand others’ speech. A relay operator types everything the hearing person says, but the individual with hearing loss speaks, too. There are now captioned telephone companies (e.g., CapTel and CaptionCall) that offer relay services over landlines and captioning through a high-speed internet connection. Videophones are available for those who communicate using sign language. A videophone user can directly call another videophone user or can call a hearing person with a relay operator who is a trained sign language interpreter. Videophone software and apps are available for use on a cellphone (e.g., P3Mobile, Purple Communications; Dinsk Videophone, Dinsk).

Alerting Devices and Services
There are dozens of devices available to monitor and signal environmental sounds and/or motion for those with hearing loss. The audiologist and patient are encouraged to work together to identify the specific situations the patient would like to address, and then find those items that work best in those instances. If you are not in a position to help search for the device, develop and provide a handout listing vendors and specific products/features the patient may want.

What is new in the field are several cellphone apps designed to provide alerts for various environmental sounds. The apps Otosense, Hearing Aide, and MyEarDroid are available in Google Play, while DeafAlarm is in the Apple App Store. These apps may have preset algorithms to identify common household sounds, or, for better accuracy, sounds may be recorded using the cellphone and saved for future identification.
New Technology, Ideas and Uses
Wireless technology can allow a smart device to act as a remote control in adjusting the hearing aids. However, these applications are not limited hearing aids. Now, many cochlear implant recipients and personal sound amplification product (PSAP) users have the ability to receive signals from Bluetooth- enabled devices such as smartphones, televisions, MP3 players, computers, and tablets.

Emergency management and notification services have made recent improvements. With potential communication challenges, those with hearing loss may find emergency situations especially scary. Mobile devices, TTYs, captioned telephones, and videophones can all be used in cases of emergency. However, services like Smart911 require a national database emergency system and an enhancement of existing 911 services. A call to 911 from a registered number triggers the safety profile of the caller, and the emergency operator has specific information for emergency responders. Smart911 also allows emergency operators to engage in a text messaging (short message service; SMS) session with the caller. More information about Smart911 can be found at www.smart911.com. Another option is using a smart device app. These emergency button or panic button apps preconfigure messages to specific individuals in case of an emergency. Video calling, such as FaceTime, Skype, ooVoo, and Google Plus Hangouts allow rapid transmission of both audio and video data.

We can often help our patients by being creative. You may have heard a common complaint from those with hearing loss, and their family and friends, about understanding what is said when shouting from one room to the next. Of course, the best practice for between-room communication is for the two individuals to come together to minimize the challenges of distance and reverberation. However, we as speakers and listeners almost invariably shout between rooms, leading to poor communication and frustration. Intercom systems can facilitate communication from one part of a building or house to another. Traditional intercom systems require preplanning or construction work to include running wire through walls, ceilings, and/or floors. This is often expensive. An alternative is to use the “push to talk” and/or the “speaker phone” feature(s) on DECT telephones to make them function as an intercom. DECT telephones allow simultaneous transmission between two or more phones, allowing both ends to speak and be heard at the same time.

Over the past couple of years, open ear headphones have entered the hearing assistive technology marketplace. These headphones allow users, with or without hearing loss, to listen to MP3 players, computers, television, etc., without blocking the air conduction pathway for hearing. Preference for the wear of these headphones may include outdoor activities such as running or cycling, when it is critically important to hear environmental sounds (e.g., traffic, sirens). One of these headphones, from Aftershokz, connects directly to or through Bluetooth to most devices, routing the signal via bone conduction. Another open ear headphone on the market, the Earhero, transmits sound via air conduction but allows for the ear to remain open. Like open fit hearing aids, this device allows the wearer to listen to the primary signal, e.g., music, while still being able to hear sounds in the environment. More information about these open ear headphones can be found at www.aftershokz.com and www.earhero.com. Although neither of these devices is designed specifically for those with hearing loss, they may nonetheless benefit some individuals with hearing loss without occluding the ear canals.

An additional creative approach to hearing assistance comes from Google. The Google Glass, a smart device worn like eyeglasses, acts like a computer peripheral device. With features like interactive controls for camera operations and wireless connectivity, these devices provide an option for bone conduction audio. Like bone conduction headphones, Google Glass audio does not block environmental sounds from entering the ear and are not specifically designed as hearing assistive technology. This does not mean that our patients cannot benefit from this technology. Additionally, Google Glass may help individuals with hearing loss by using a feature that projects live, automatic, and pre-scripted captions, subtitles, and manual interpretation onto the lens. Additional information about Google Glass can be found at www.google.com/glass.

Finally, downloadable applications, or apps, for smart devices can be used to assist those with hearing loss. Like PSAPs, amplifier apps may be appealing to those with hearing loss, but are not designed to take the place of hearing aids, although, many of these apps have a noticeable time delay. Speech-totext apps like ISeeWhatYouSay (angel.co/digital-army-devices) is an Android-based app that uses automatic speech recognition (ASR). As a person speaks into one smart device, the text is displayed on another smart device. Other apps, such as sound level measurement and reverberation apps, may be useful in measuring listening environments. Although measurement accuracy is mixed among apps, these apps may be of value when acoustically modifying a room.
Conclusion
We as audiologists should remember to take into consideration, our patients’ hearing and listening needs--to include listening environments, communication partners, comfort level with modern technology, and the utility of rehabilitation, to name a few. These considerations apply to the selection and fitting of hearing aids and implantable devices, but also apply to the role hearing assistive and access technology provide and/or complement hearing aids and implantable devices. Telecommunications access, visual-based communications, alerting devices, and smart devices, among others, can provide individuals with hearing loss many well established and some new options for establishing equal access to information, education, and the joys of a hearing world. More importantly, these technologies are not static and neither should our views towards them be. We are charged with finding new and creative ways to use these and other everchanging technologies to assist our patients.    
Clifford A. Franklin, Ph.D., is an audiologist and associate professor in the Department of Audiology and Speech Pathology in a consortium between the University of Arkansas for Medical Sciences and the University of Arkansas at Little Rock. With more than 17 years of experience as an audiologist, his clinical experiences include working in university clinics as well as in a hospital setting. Dr. Franklin’s clinical experience has contributed to his interest in hearing aid use. His research is mainly focused on the acceptance of background noise while listening to speech. He is co-author of Hearing Assistance and Access Technology, and has 42 national and international presentations and 17 publications to his credit.

Laura Smith-Olinde, Ph.D., an audiologist and associate professor, is the Director of the Educators’ Academy at the University of Arkansas for Medical Sciences. Before taking this position, Dr. Smith-Olinde taught in audiology and speech pathology programs for 16 years— most recently in the Department of Audiology and Speech Pathology in the University of Arkansas for Medical Sciences and University of Arkansas at Little Rock consortium. She also served as the coordinator of the Infant Hearing Program for the Arkansas Department of Health for 18 months and obtained grants from the Centers for Disease Control (CDC) and Health Resources Services Administration (HRSA) for that program. With more than 30 publications with more than 80 presentations to her credit, Dr. Smith-Olinde is also a co-author of Hearing Assistance and Access Technology.

Samuel R. Atcherson, Ph.D., is an audiologist and associate professor in the Department of Audiology and Speech Pathology in a consortium between the University of Arkansas for Medical Sciences and the University of Arkansas at Little Rock. He has a secondary appointment as an adjunct clinical associate professor in the Department of Otolaryngology-Head and Neck Surgery. Dr. Atcherson has presented more than 130 times on an array of topics related to hearing loss, electrophysiology, hearing assistive technology, and healthliteracy issues. In addition to co-authoring Hearing Assistance and Access Technology, he has more than 95 publications, including two books and eight book chapters. He has more than 85 publications, including two books and six book chapters. Dr. Atcherson is familiar with and benefits from hearing assistive and access technologies—he is a bilateral cochlear implant user with previous hearing aid use of more than 30 years. A healthcare practitioner with hearing loss, he is past president of the Association of Medical Professionals with Hearing Losses and a founding leader of the Association of Audiologists with Hearing Loss.

Please direct all correspondence to Dr. Franklin at CAFranklin2@ uams.edu.
References
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Atcherson, S. R., Franklin, C. A., & Smith-Olinde, L. (2015). Hearing assistive and access technology. San Diego, CA: Plural Publishing.

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Much of the information covered in this article is discussed in greater detail in Hearing Assistive and Access Technology, a new textbook written by the authors of this article.