Associate Director of the Adult Amplification Program at Vanderbilt University Medical Center, US
Gina specializes in the diagnosis and rehabilitation of adults with hearing loss, and served as the Clinical Trials Coordinator at the Vanderbilt Bill Wilkerson Center for five years. She earned her Doctor of Audiology (Au.D.) from Vanderbilt University School of Medicine in 2010, prior to which, she received a Bachelor of Science in Communication Sciences and Disorders from Syracuse University.
During the initial development of Remote Support, Sonova used an iterative process to create a remote fitting prototype. This allowed us to learn from audiologists and clients, and implement those changes directly into the prototype. Dr. Angley and I worked together on the first study we did looking at remote fittings as a new service delivery model. It was very exciting to explore this topic together in the real world and learn about the potential benefits, as well as the limitations. eAudiology has certainly come a long way in the last years, and it is my pleasure to interview Dr. Angley on this topic today.
Here is our interview…
Could you share with us how you became interested in eAudiology?
In all honesty, I became aware of this service delivery model by participating in a study evaluating the technical feasibility and potential benefits of remote fitting of hearing aids. Prior to that time, I was not even aware that the hearing aid industry was exploring this as an option. After becoming involved in the study, I quickly realized eAudiology could have a huge impact on the profession, and how we treat patients. That is when my interest in the area really sparked and grew.
Can you tell us why you feel eAudiology is an important topic for hearing care professionals?
I think you have the obvious reasons like accessibility and cost. Accessibility to quality hearing healthcare can be difficult depending on where in the world you reside. For some, access might be easy, but for many it can be difficult to get to a clinic. It may also require time off of work, which means lost wages and loss in productivity for the company.
The not so obvious reason is, we may be able to provide our patients with better hearing healthcare by using eAudiology. We all know that dance of the patient coming in, they express their concerns, and we must make educated decisions on how best to address their concerns from the information they provide, which is often times limited. The patient then leaves the clinic to try the new settings and returns in a few weeks to report on their progress. If there are still concerns, then we will make more adjustments based on their report and back out they go to try the settings again. Now imagine if we could be in the situation with the patient and address the concerns in real time. It could potentially cut down on the number of office visits they make and how much time we are spending with one patient. eAudiology could be the solution to truly optimizing the hearing aid for the patient’s listening environment and challenges.
What do you think are the barriers keeping clinicians from using eAudiology?
Like anything in life, change can be hard. This is an abstract idea and a far departure from how we have served our patients up until now; however, our patients are becoming more educated and involved in their healthcare and how they receive that care, so we must adapt ourselves to meet that need.
When I began my journey with eAudiology, I had questions about where to go to get helpful information, questions about licensure guidelines surrounding eAudiology services, and questions about how to talk to patients about these new services. If you are thinking the same thing, those are all good questions to have. In addition, to resources provided by Phonak, the American Telemedicine Association, American Academy of Audiology and American Speech-Language Hearing Associate all have great resources for providers, too.
Your recent research is giving us valuable insights into the feasibility of remote hearing aid fittings. Can you briefly share your findings?
The short answer is – yes, remote hearing aid fitting works and the majority of the remote appointments (80%) were viewed as being as efficient as face-to-face appointments. In addition, provider satisfaction was high (82%) and participants indicated under difficult conditions they would prefer eAudiology appointments (86%) and they would recommend (90%) eAudiology appointments to others. All the participants preferred when the provider used a camera over telephone use only, and most indicated that they enjoyed being able to see the provider (88%) and felt comfortable using a camera themselves (94%).
Did you identify perceived benefits of remote hearing aid follow-up care? Were there limitations?
The benefits indicated by participants were as expected – time savings, convenience and reduced travel costs. For the provider, over time, follow-up appointments were shorter, and eAudiology eliminated the need for a fully functional hearing aid room. To conduct remote appointments, you do not need a booth, a Verifit, programmers, multiple chairs, and ample space to accommodate several people in a room. For eAudiology you need a quiet room, a desk, a chair, a computer, and a camera. This opens your revenue generating spaces to see consultations, fittings and other income generating services.
The limitations we observed were the patients needed to have access to quality internet services. Now, while the current solution is not dependent on internet access, it does depend on quality cellular service or Wi-Fi. If this is not available, then it could result in poor audio or video, which in the study, decreased the providers satisfaction of the appointment. The obvious limitations for the provider are you cannot verify hearing aid output, if needed, and you cannot physically inspect the hearing aid. You are going to rely on the patient’s ability to manipulate the devices if you need to troubleshoot hardware components. If you have ever tried to hold your cell phone in one hand, while showing something in your other hand, you know that can be very difficult, and we would be asking our patients to do just that. This could potentially lead to frustrations for both you and the patient.
What are the key considerations for setting up a remote hearing aid fitting session?
As you begin your eAudiology journey, there are provider and patient set-up considerations, as well as appointment considerations that you need to work through. For provider set-up, I would encourage you to evaluate your clinic space first and see if you can find an appropriate place to conduct eAudiology sessions. Remember you do not need a fully functional clinic room to provide these services. What you do need is a quiet space, with good lighting, a simple background, a computer (preferably with two monitors), and a camera.
You want to be cognizant with your lighting to make sure you do not have any shadows on your face that could impede the patient’s ability to read facial expressions and lips. The background should be simple and provide good contrast when you sit in front of it. You do not want to blend in with your surroundings. I suggest two monitors as it can be a bit cumbersome to click back and forth between different programs and screens you have open when using one monitor.
With two monitors you can spread everything out and more easily see what you need to, while keeping a good view of the client chat window. When you set-up your camera, play around with the distance and angle of the camera. You want to be eye level and far enough away that as you glance from one screen or program to the next it continues to look like you are facing and looking at your patient.
As you prepare your patients for eAudiology appointments, there are a few considerations they need to be mindful of as well. As silly as it might sound, we do need to remind our patients to dress appropriately. When patients come to our clinics, they understand they are going out in public and must dress accordingly. With eAudiology, it is possible they will be in the comfort of their own home, and so they might be more relaxed in their clothing and what they choose to wear. Patients should also turn off any distractions in their environment. I had one patient watching television while we were trying to conduct an eAudiology appointment, and it was not until we were about halfway through the visit that I found this out. Unless the distraction is a concern the patient has and you are addressing this during the remote fitting, they should minimize environmental disturbances and be engaged in the visit.
You have found the space in your clinic that will be used, now you must think about what the workflow is going to look like for eAudiology appointments? How will your patients be checked in? What information will be relayed to your patients to ensure they are looking at the correct screen on their phone? Will patients complete a feedback survey after the appointment? These are just some of the questions to think about and discuss with your staff.
In addition to outlining your clinic workflow with eAudiology, you also want to prepare yourself for the appointments. If you have ever completed a video chat with someone, you have probably experienced the awkwardness of looking in the camera lens to give the other person the perception that you are looking them in the eye. It is very difficult and unnatural to look at a camera lens and not the person’s face on the computer screen. For this reason, you need to practice. You also need to practice describing what you are doing. In a face-to-face appointment your patient can see what you are doing, they can see that you are connecting and adjusting their hearing aids or reviewing their medical record.
In an eAudiology appointment, the patient cannot see your screen, so you have to describe what you are doing to keep the patient engaged and informed during the visit. For example, you might say to the patient, “Mr. Smith, it sounds like we need to add a noise or restaurant program to your hearing aids to address your concerns. I will go into the fitting software and add a manual speech in noise program into your first program spot. Okay this is done, and now I’m going to activate your program button. Okay, this is turned on. Now you can access this new program using the hearing aid or using the phone application.”
How would you recommend presenting this to a patient?
As I previously mentioned, I think one of the barriers to adopting eAudiology, is providers do not know how to start the conversation with a patient. The concept of eAudiology is abstract right now. Where I have found success in recommending this to patients, is I do my research before the patient arrives and I actively listen during our appointment to see if eAudiology could fill a need.
What I mean by research is I look at their chart and see if I can find a reason to bring up eAudiology that might make the hearing aid process easier for the patient. I am looking to see from the distance they travel, their age, if there is anything that indicates they rely on others for transportation; find something that you can use as your conversation starter with the patient. For example, “Ms. Jones, I see you had to drive quite the distance to see us today. As we discuss hearing aid options, I would like to talk about an option called eAudiology that you might find helpful. eAudiology would allow you to stay at home for your appointments but still receive hearing aid follow-up care by using your smartphone. This would minimize the need for you to drive into the clinic to see us. Would you like to hear more about this option?”
If, when you are reviewing the patient’s chart, you do not see anything that could be used as your conversation starter, then listen for opportunities in your discussions with the patient once they are there. If the patient is always asking for appointments first thing in the morning or the last appointment of the day so they do not have to take time off work, then use that. “Mr. Smith, I see you are always asking for the last appointment of the day because of work. I would like to talk more about eAudiology with you, as I think this option could be helpful for you. With eAudiology we could connect with each other, using your cell phone, and address your hearing aid concerns. We could do this while you are on your lunch break, for example, and you would not have to drive to the clinic to have your hearing aid concerns addressed. Shall we talk more about this option and schedule your next visit using eAudiology?”
Regardless of who you present this option to, start with the easy patients. We can all think of those patients who are comfortable with technology, or who always want to try the newest thing, or whose concerns are not overly complex. Start there. Keep as many factors as you can simple, so you can focus on preparing for the appointment and delivering eAudiology services well.
Keep as many factors as you can simple, so you can focus on preparing for the appointment and delivering eAudiology services well”
Finally, could you give us 3-4 tips of what clinicians can do Monday morning to make themselves eAudiology ready?
Some action items for Monday would be to first evaluate your space. As I mentioned earlier, you do not need much to conduct an eAudiology appointment – a quiet space, a computer, a camera, and maybe a lamp depending on the lighting in the room. Find this place in your clinic so you can free up your revenue generating rooms to complete appointments that will financially support your clinic.
Second, I would think about ways to use your support staff. While the process to set-up a patient account in the app has been simplified, some patients may still struggle. This is a process we can train and instruct our support staff to complete with patients. Also, think about how you are going to have your front desk staff check-in your eAudiology appointments? How far in advance do you want them to call the patient to check them in and prime the patient for the appointment? What might they say or remind the patient to do to ensure they are on the correct screen in the app?
Once you have outlined the logistics of providing eAudiology services, then review your clinic schedule for potential patients. Remember, start with the easy patients first and then as you become more comfortable with eAudiology, you can expand to more complex patients.
Lastly, you want to practice, practice, practice! Providing eAudiology services has a very different feel than face-to-face appointments do. Where you look, how you look, what you say and how much you say is all going to be different. Set up mock appointments with family, friends or colleagues and get feedback from them. Ensure you look engaged during your “appointment,” did you explain enough of what you were doing? Did you introduce everyone in the room with you? Even though I have experience with eAudiology, I continue, to this day, to modify my approach, what I say, and how I navigate between screens. I always take time at the end of every appointments to reflect on how it went and what I could have done to improve the patient experience and service. I would encourage you all to do the same. Just like any other clinical task, your approach will evolve as you gain more experience and become more confident.
Summary of Gina Angley’s tips to make yourself eAudiology ready this Monday morning:
1. Evaluate your space and set-up needs.
2. Think about ways to use your support staff to improve the process.
3. Review clinic schedule for potential patients (starting with easy patients first).
4. Practice, practice, practice. Your approach will evolve as you gain more experience.
For further guidance on how to implement eAudiology into your practice, access the guides in the ABC’s of eAudiology on phonakpro.com
Theory to Practice is a series of interviews with experts in the field of audiology and beyond. Interviewees share their knowledge and insights on relevant topics. The special focus of each interview is to translate theory into key take-aways which can be implemented into daily practice.