Customization is the Antidote for Automation

Author: Brian Taylor, Au.D.

If you followed the unveilings at CES 2020 in January, it’s apparent that hearing aids continue to morph into consumer audio devices, as a growing number of consumer audio devices transform into hearing aids. Because these devices have multiple functions, they can be classified as hybrid devices. That is, they can be used to stream music, talk on the phone, track biometrics, and amplify speech. Obviously, a greater number of choices, spread across a wide range of price points, is a positive development for consumers with hearing loss, especially for millions of people with hearing difficulties who don’t want or value interventions delivered by audiologists. According to a recent MarkeTrak 10 article by Brent Edwards, published in Seminars in Hearing, about 7% of Americans have no measured hearing loss but perceive hearing difficulty, and another almost 8% of Americans have measured hearing loss and perceive no hearing difficulty. Both of these groups are unlikely to see themselves as hearing aid candidates and could enbrace some type of do-it-youself, off-the-shelf solution.

The convergence of hearing aid and consumer audio technology might be appealing to these two groups for different reasons. For those with no measured hearing loss but perceiving hearing difficulty, hybrid devices, with their multitasking capability can be used as a situational hearing aid in challenging listning places, encountered a few times each week. In contrast, those with measured hearing loss and perceiving no hearing difficulty, family and friends can encourage them to try an amplification device from the comforts of home without scheduling an appointment with an audiologist.

The emergence of hybrid devices will enable more people to opt to self-direct their own care—the ability to self-assess, self-diagnose, self-treat and self-manage one’s own condition with little to no direct involvement with a licensed professional.

Let’s explore some of the underlying reasons driving the trend toward self-directed care. A closer look tells us there are two trends driving some individuals to self-direct their care. At the center of each trend is the smartphone, smartphone-enabled apps and a wireless internet connection, which, together, form a user-friendly self-directed care system.
Democratization of Technology
Many of the tests and procedures conducted in the clinic by audiologists can be placed in the palm of the consumer’s hand, allowing them, with smartphone and machine-learning apps, to self-screen for possible ear disease, self-test their hearing or even self-fit hearing aids. These are all part of a larger movement aimed at democratizing all of healthcare. Even if a patient chooses to make an appointment for a comprehensive hearing assessment, the standard test battery can be completed by a non-audiologist using automated equipment. If you’re an aging Baby-boomer or Gen Xer who has grown up experiencing the marvels of both modern medicine and Madison Avenue marketing, there’s a good chance you find this new-found ability to self-direct your own health care incredibly appealing.
Decoupling of the Buying Process
Until recently, if you have hearing loss and decided to purchase hearing aids, the entire sales and service acquistion process took place in a fairly linear manner, as outlined in Figure 1. All components of the buying process typically occurred with the same clinic, under the same roof. In a sense, persons with hearing loss were hostage to the location in which they decided to do business. The costs of switching to a new provider meant developing new personal relationships with new service providers, an often times consuming and stressful process.
Figure 1. The traditional linear buying process with five key phases, delivered by the same clinic

Now, thanks to modern technology, each phase of the buying process can be delivered by a different clinic or service provider and each of the five phases, importantly, can be delivered either face-to-face or virtually, using webcasting, video chatting or some other form of computer-based communication. Figure 2 and Figure 3 show two examples of a decoupled buying process, in which the consumer with hearing challenges acquires a different component of the buying process from three different entities.
Figure 2. An example of the decoupled hearing aid buying process

Figure 3. Another example of the decoupled buying process

Given the nature of hearing loss that’s gradual in onset, its accompanying social stigma and the natural inclination to procrastinate intervention for a chronic condition, both the democratization of technology and the decoupling of the buying process enable consumers with hearing challenges to dabble, test drive and experiment with various assessment tools and treatment options in a low-risk manner from the comforts of home or with the help of family and friends.

The democratization of technology combined with the decoupling of the buying process means consumers can choose when and what parts of the buying process they want customized by an expert professional. And, in contrast, they can decide when and what aspects of the buying process they want standardized/automated. You can think of the choice between customization and standardization/automation as one that lies on a continuum, like the one shown in Figure 4. For every component of the buying process, from evaluation to on-going service (See Figure 1), the consumer with hearing challenges can decide if it’s worth the time and money to have all or some aspect of the buying process customized. Customization, it would seem, of all or some part of the buying process more likely leads to an optimal outcome. On the other hand, an automated or standardized one-size-fits-all process, which saves either time or money, more likely leads to an outcome that might be "just good enough."
Figure 4. The Customization-Standardization/Automation Continuum. Customization takes more time but it’s more individualized and more often lends to an optimal outcome. Standardization and automation require less time, tend to reduce cost for the patient and more often lead to an outcome “just good enough” for the patient.

Clinicians may soon even practice in a world where customers with hearing challenges begin the process in the clinic with a face-to-face visit. After an initial intake, the clinician and consumer mutually decide if the rest of the buying process should be automated or standardized with little or no further direct involvement from the professional.

Today, clinicians are already grappling with providing services on this customization – standardization/automation continuum. There are several components of the clinical delivery process that can be standardized or automated, thus saving considerable time, but possibly sacrificing an optimal outcome. Every clinician uses a standardized procedure to measure hearing thresholds and speech understanding ability – components of a standard assessment that can be completed with automated equipment in the clinic today. And, many clinicians rely on first fit algorithms as a starting point in the fitting process and don’t use probe microphone measures to customize the fitting. Any test, procedure or interaction in the clinic with a patient can be placed somewhere on this continuum.

It seems clear that if hearing care professionals want to remain relevant for most consumers with hearing challenges, they must identify ways to customize as many parts of the buying process as possible. Furthermore, it makes sense to provide this customization in an ala carte format, allowing consumers the ability to chose what they want customized. Below are some examples of how hearing care professionals can differentiate their practice through customization for each of the stages of the buying process. Each of the components below could be an unbundled fee for service provided by an audiology practice.
1. Evaluate: Customize Information Gathering and Treatment Goals
Gather as much information as you can about the person’s auditory system and the underlying non-audiological factors that contribute to their handicapping condition. Use scaling questions to gauge the patient’s perception of hearing loss and their willingness to take action on a treatment. In addition to standardized tests like the Quick SIN, use established questionnaires like the Revised Hearing Handicap Inventory Screening to ascertain the patient’s self-reported emotional and social factors affecting communication ability.

Finely tailored information gathering leads to the development of bespoke treatment goals that can be recorded on the COSI or Patient Expectation Worksheet. Gathering detailed information about the person (not just their auditory system) and devising individualized treatment goals cannot be easily replaced by machine-learning algorithms or standardized tools found on an app or website. This information gathering is a humanistic skill provided by conscientious professionals.
2. Choose:Customize Treatment Options
One of the tenets of patient centered communication is that the consumer with hearing challenges and the service provider are working together to identify treatment goals and options. By using a patient decision aid, like the one shown in Figure 5, clinicians can educate consumers about a full range of options, including options that may be “just good enough.” It is the responsibility of the clinician to educate the consumer about the pros and cons of every potential treatment option, even those that may be sub-optimal.

Effective decision aids show more than device options but can include the option of doing nothing or forgoing the use of a device and trying some type of stand-alone aural rehabilitation or auditory training program. Patient-centered communication means the provider is clearly articulating the pros and cons of each option based on the information gathered during the evaluation.
3. Purchase:Customize the Fitting
Regardless of where a consumer may have purchased hearing devices, professionals have an opportunity to provide quality control measures to ensure the physical fit and acoustic parameters are optimized. One proven strategy is to use a scientifically validated prescriptive target and verify the match of that target with probe mic measures. A 2018 study by Valente and colleagues indicates that squeezing an extra 5 to 8 dB out of the fitting, getting the first-fit starting point closer to an individualized prescriptive target, improves speech understanding by upwards of 20%. The challenge for clinicians, of course, is that they don’t always have familiarity or access to fitting software that allow them to make these necessary adjustments on devices purchased elsewhere. A challenge that could be addressed by changes in FTC hearing aid regulations.
Figure 5. An example of a patient decision aid used to customize treatment options
Options for Hearing Treatment
Near NormalModerate Very Challenging
YOUR OPTIONS Minimal Action Personal Sound Amplification Products (PSAPS) Hearing Aids Hearing Systems Baha and Cochlear Implants
PROS Annual hearing checks are low maintenance and low cost. Maintaining healthy hearing ensures best overall health. Inexpensive, over-the-counter option for people with little to no hearing loss that may help to amplify sound. Hearing aids are considered the gold standard of treatment for hearing loss. Proper fit, followup, and counseling from an audiologist results in high satisfaction with devices and improved quality of life. Better signal to noise ratio, remote microphones, wireless streaming to TV and phone, adjustments and programming. Cochlear implants are an effective longterm solution for treating hearing loss
CONS Untreated hearing loss can lead to a variety of negative health conditions, including depression, cognitive decline and dementia. Inadequate fit and follow-up often leads to disatisfaction with the product. Low quality technology leaves a lot of room for improvement with your hearing. The upfront cost can be a concern for patients. Luckily, financing options are available. Need to carry additional accessories on hand, some hearing systems have limited range. Surgery is required for implantation.
4.Use and On-going Service: Customize Self-Management Plans
More than simply teaching patients how to use their hearing aids, clinicians can customize an individual’s self-management plan. People with chronic conditions, like hearing loss, benefit from learning how to be independent communicators and problem-solvers. Since the condition cannot be cured but can be effectively managed, the goal of the professional is to devise a self-management plan, targeting key areas of improvement for the individual. A self-management plan focuses on improving one of the three components of self-management:
  1. Knowledge of the condition and treatment options,
  2. Actions that improve the patient’s condition, and
  3. Psychosocial issues resulting from the hearing loss that need to be overcome or addressed through long range planning and support from a professional.
An individualized self-management plan is an iterative process, which means that it is likely to change over time. Therefore, at least once a year the consumer and provider should sit down together (in person or virtually) and update the plan by modifying goals and communication strategies.

These are four examples of how audiologists, relying on patient centered communication skills, can customize any link of the buying process for individuals who have the choice of self-directing their care. As a larger number of routine clinical tests, procedures and products become automated and democratized, it is imperative for audiologists to excel at the humanistic ability to tailor all components on the buying process in an ala carte manner. Customizing the consumer’s purchasing experience can be the antidote to automation.