The Community Hearing Health Network: The Kiosk approach, Transforming Threats into Opportunities



Author: Mark Kaal, MSc

When it comes to using self-service kiosks and other devices, consumer trends have changed. There is widespread acceptance and usage of many self-service programs. Despite the current economy, the number of kiosks deployed every year is growing and there are many reasons to believe this trend will continue. Increased customer interest, growing demand from end-user businesses, and technological advances are all fueling the growth of kiosk applications and deployment. In the past 12 months, hearing screening kiosks have been introduced in the US market. None of these products intend to replace a full hearing test. That is important to stress as self-administered hearing tests recently have been drawing quite a bit of attention in the audiology community and also from a regulatory perspective.

This article discusses the use of these kiosks for hearing screening in order to give the public an opportunity to get a first impression of their hearing health, thereby promoting general awareness of possible hearing loss as well as providing the opportunity for “next-steps” counseling by an audiologist or physician. Used in the right locations and embedded as a critical part of your marketing communications strategy, kiosks can be very valuable and affordable tools for attracting new patients to your practice.

History
Hearing screening kiosks are not entirely new. Early pioneers like Boulder, Colorado audiologist Dr. Christopher Schweitzer started experimenting with them during the late 1980’s. This early experience was mixed. On the one hand, it was demonstrated that self-test kiosks can be an interesting tool to help promote hearing health awareness in the community and also bring new patients into a practice. On the other, a kiosk operating in a public space needs to be robust and well designed for that purpose. The obvious advantages of remote communications, monitoring, and calibration checks needed to wait for the enabling of the digital age.

Around the time that Dr. Schweitzer was experimenting with an analog version of a kiosk, Canadian audiologist Errol Davis started developing software as a reliable technology for screening workers in noise exposed environments. Although the practical purpose of the initial software was obvious, he also wanted a tool that could help deal with a person’s denial of their hearing loss when tested for the first time.



Errol has a lengthy experience that includes appointments as Assistant Professor at the Department of Otolaryngology, University of Toronto, Audiologist-in-Chief of the Toronto General Hospital and Director of Audiology of The Canadian Hearing Society. In addition to his academic credentials, he has and continues to serve as a dispensing audiologist and business owner in large ENT/Otolological practices in Southern Ontario.

Over the years, the test engine he developed has been used for a variety of applications. Looking for a suitable partner to bring this unique technology to the market in kiosk form, Errol teamed up with Ultimate Kiosk Inc., a Canadian growth company. Their Ultimate Kiosk, equipped with the latest third generation software, was presented at the recent Audiology Now! Show in Boston at the booth of the company’s partners, Hearing News Network and Clearsounds Communications.

The Challenge: Embedding Your Clinic in the Community
Community outreach activities have, over the years, become an increasingly important part of modern clinic management. How to implement these activities in the busy schedule of running your clinic and serving patients is often very challenging. Making hearing health into a conversation topic and at the same time promoting your clinic as the most logical next step towards treating hearing loss is the key combination. Besides the time spent and the effectiveness of the various outreach activities, having prospective patients come to your clinic when they are actually ready to pursue treatment for their hearing loss, is also important.

A network of kiosks, located in strategic locations that attract the right demographic of people in a health conscience mode, might help you achieve these goals. Depending on the location, the awareness for hearing health issues might be raised by linking it to other health issues. Well documented are relationships between hearing loss and types of vision impairment, Type 2 diabetes, arthritis, high blood pressure and most recently, dementia. The kiosk can be regularly updated with general publications about hearing health, provide educational materials and promote your clinic’s activities. It allows you to connect with people in a non-confrontational and time effective manner, helping them understand their hearing and what can be done about it. On average it takes about seven years for people to seek treatment after they have discovered that they probably have a hearing loss. Typically, a socially embarrassing situation or an almost near death experience serves as the final call to action.

As people can take as many hearing screenings as they want via a kiosk, reinforcing their status on each occasion, chances are good that their journey will be shortened.

Kiosk Versus Online Tests
There’s been considerable controversy in recent months (e.g., The Hearing Journal, May, 2012) over the ethical practice merits, or transgressions, of ‘on line’ hearing testing. Hence, a few comments about pertinent differences between a kiosk and online testing are in order. Naturally the first remark in making any comparison is that we are only comparing these tests from a strictly non-medical perspective. This does not mean that reliability is unimportant, especially to avoid false positives or false negatives. There are several ways of conducting a pure tone hearing screening. Asked by the author (who is not an audiologist), Errol Davis gave a high level explanation of the various methods used:

“Some on line hearing tests combine a series of pure tone averages but this method does not identify accurately the pattern of hearing and produces false positives and, worse, false negatives. Other, even more rudimentary systems, draw an arbitrary line across the audiogram and report those above a point as normal and those below as abnormal. This method produces an even greater number of false positives and false negatives when only the level of hearing is used to interpret pure tone test results. The Ultimate Kiosk uses embedded artificial intelligence to classify hearing by pattern and level. The whole objective is to provide a hearing screening methodology that yields the best estimate.

Another element of comparing the quality of results is that a kiosk should be calibrated. Background noise is another concern shared amongst many audiologists. Errol Davis on the subject: “Background noise in the majority of cases becomes a distraction during the course of a hearing ear screening. It has little impact on actual threshold changes except in extreme cases where it can cause a shift in hearing by 10 dB, in some instances 15 dB at 500 Hz when a person has normal hearing at 500 Hz. Using embedded artificial intelligence, one can identify this shift and its impact on the pattern and level change. The use of noise canceling headsets can also be of benefit in situations where high background noise is present along with real time monitoring of the noise level. Sampling of noise prior to a test and/or a change in the location of a test can be of some use. For pure tone screening purposes, however, its cost often does not justify the limited impact on the small number of tests background noise affects.“

Further, as earlier stressed, it’s important that your clinic be embedded in the community. An online test typically is not so as it is delivered via the relatively anonymous Internet. Putting kiosks in locations that people consider to be a trusted environment seems therefore to be a more logical path. Another factor that should be taken into consideration is the quality of the referrals. As various manufacturers offer more online referral generation through websites, the quality of referrals has become an issue, not only from a value for money perspective but also given the impact it conceivably could have on the perceived quality of your clinic.

Kiosk Experiences
Ontario trial
Last year, a trial was conducted in Ontario with four kiosks placed in different locations - a standalone pharmacy, a pharmacy/medical clinic combination, a medical clinic and a medical/dispenser combination. Over a three month period, these kiosks collected hearing test results of 586 clients (1,172 ears) representing an average 48 tests per kiosk per month. The study was comprised of 260 males (44.4%), 191 females (32.6%) as well as 135 others (23.0%) who declined to provide gender information. 129 clients (22.0%) did not provide age related information. That said, more than 75% of clients were willing to provide information related to age (78.0%) and gender (77.0%). 15% of cases indicated a hearing loss consistent with the probable need for a hearing aid, representing 7- 8 qualified referrals per kiosk per month. The two that included a closed feedback loop (with an audiologist and/or dispenser) reported kiosk-related sales of 3-5 units/month. The dispenser connected with a kiosk in a medical clinic had the highest conversion rate – the majority of those with an indicated hearing loss (wearing no hearing aid at the time) were prepared to book an appointment.

Canadian Pharmacies
Also in 2011, 16 kiosks were placed in pharmacies in Southern Ontario and Alberta and linked to a hearing health professional covering multiple locations. These kiosks were of a first generation that was not web enabled, so the data collected is not that extensive. The results available, however, are in line with the Ontario trial. A full roll out into their Canadian locations is now well underway with another 50 kiosks ordered for delivery in Q2 and an additional 50 forecast for later in the year. The majority of these units will be located in Walmart Canada stores.

U.S. experiences
Given his early work on kiosks, it is not surprising that Dr. Schweitzer is under one of the first in the US to build up experience. As advisor to Ultimate Kiosk, he is recommending adjustments in content to match US preferences as well as testing location strategies. His original location was at a senior center where positive responses (based on 1-2 tests per day) were confirmed by the location manager and visitors. Surprisingly though, these positive responses did not so much trigger email appointment requests. One of the conclusions drawn, therefore, is that effective communication and follow up strategies need to be employed to fully exploit the kiosks potential.

Effectiveness
The kiosk is first and foremost a communication tool. To use it effectively means that it needs to be embedded in the overall marketing communication strategy around your practice. Depending on the location, these could include follow up events and invitations, using the kiosk to give general hearing health information and other materials including incentives for pursuing follow-up testing with your clinic. Kiosks can also be branded, both hardware and software, so that they are consistent with the brand values of your clinic. This makes the kiosk truly integrated into your daily practice management.

It is difficult to compare the kiosk on a cost per referral basis compared to alternative approaches. The monthly operating costs of a kiosk are between $200 and $250 (including amortization). Some kiosk providers charge per appointment and per report generated, pricing methods that might significantly impact monthly operating costs. Experience with The Ultimate Kiosk suggests that about 6-8 qualified referrals per month is a reasonable expectation. If this number holds as an average, the kiosk seems to be a very cost effective solution.

Trends
Hearing screening kiosks were introduced in the US market during 2011. The earlier models were relatively expensive but as more vendors offer kiosk solutions, pricing will become more competitive. More variation in hardware (screen size, full public environment or more controlled environment, printer, noise cancelling headphones) will also become available.

Another trend, most likely starting this year, is further usage of kiosks for promoting hearing health awareness. An example of this is a recently announced partnership between the Hearing News Network and Ultimate Kiosk, allowing the kiosk to broadcast hearing health information for instance by the BHI, when not in hearing screening mode. As kiosks when used should really be integrated into daily practice management, linking with customer relationship management systems and practice management software is a logical next step. So far, hearing aid manufacturers have not been actively endorsing kiosks, but this will probably soon change. As manufacturers incorporate kiosks in their endorsed practice management kits, a further reduction of the operating costs is very likely.

In some locations, a full blown kiosk, designed for use in a public space might not be suitable. In certain locations, tablets might be the appropriate solution for hearing screening.

Getting Started
Getting started with kiosks is fairly simple. The most important first step is to scan your community for the best locations for kiosk placement. As kiosks are mobile, they need not remain in a permanent location but could be moved to different locations over time, or used for events.

After one or more locations have been selected, choosing the right vendor and product is next. Different pricing models exist and these differences can impact your monthly operating budget. Other questions to consider include: Is the kiosk suitable to operate in the desired environment? Are financing options available? What warranty and service level agreements do I need? And certainly, make sure that you always are the owner of the data that the kiosk generates from the moment it starts operating.

After a selection has been made, the kiosk needs to be set up according to your preferences. In some cases, vendors charge an additional amount for this set up; with others, it’s included in the basic package. After arrival, the kiosk should really be a plug and play device that is easy to operate. Web enabling is preferred to allow remote updating and maintenance of software, content management as well as to facilitate communication and appointment making between user and clinic.    
Mark Kaal is Founder and CEO of Samplified Audio Solutions Inc., a Toronto based company advising on emerging technologies in the hearing health space that can support reaching out to the (on average) 75% of the hearing impaired that are at present not serviced. Before founding Samplified in 2011, Mark was Founder and CEO of hearing aid manufacturer ExSilent BV in Amsterdam, the Netherlands. He can be contacted at mkaal@samplified-audio.com.
Disclosure
Samplified Audio Solutions Inc. provides strategic consultancy services to Ultimate Kiosk Inc.
Acknowledgments
The author wishes to thank Errol Davis and Christopher Schweitzer for their input and advice.