Telehealth is coming to the hearing care profession, and it will be everywhere from a pediatrician handing you the Georgia Tech Remotoscope attachment for your iPhone to monitor your child’s ear infection, to the Sydney Cochlear Implant Centre (SCIC) remotely MAPping CI’s across Australia and throughout the South Pacific, to speech-language pathologists providing “clinical face time” to clients in rural areas, to Bristol PA-based America Hears and Melbourne-based partner Blamey & Saunders (formerly Australia Hears) remotely programming hearing aids, to using online auditory rehabilitation programs such as Neurotone’s LACE with patient compliance monitoring integrated into Sycle.Net practice management software, to CI’s e-mailing implant and processor health & reliability data silently in the background… And so much more, still to be dreamed up.
In this article:
• Benefits of Telehealth
• Telehealth in the Hearing Aid Professional setting
• Step-by-step instructions for enabling Telehealth for the ReSound Alera and Verso, and Widex Clear, Super and Dream hearing aids
There are numerous benefits to using Telehealth in hearing care:
- In situ resolution of hearing aid & CI performance issues while the patient is in the actual work or school environment;
- Access for both routine appointments and emergency problem resolution from early morning to late at night when a pool of clinicians is available across multiple time zones;
- Top professionals in the field can see more patients for difficult-to-solve problems beyond the abilities of the local clinician;
- Access to the physician or hearing care professionals when the office is closed, or when the clinician is traveling;
- Patient convenience in not having to travel in city traffic or long distances;
- Access to quality hearing care for shut-ins without expensive and time consuming ambulette transportation;
- Resolving problems while the patient is traveling.
Of the various issues above, two are worth delving into, because they are not readily apparent:
1) In situ resolution of hearing aid & CI performance issues while the patient is in the actual work or school environment: For example, let’s say a nurse is having trouble performing auscultation, a student needs her FM/mic balance adjusted, or a bartender is having trouble understanding the waitress. Under the current health care delivery paradigm, the nurse would have to take off from work and bring her gear with her for a simple adjustment, the student would wait a few days until the school district audiologist showed up… And the bartender would be pretty much SOL, having to return numerous times for trial-and-error problem resolution relying on his problem descriptions. For all three of these scenarios, Telehealth allows the hearing care professional to rapidly and effectively resolve problems when and where they are occurring;
2) Access for both routine appointments and emergency problem resolution from early morning to late at night when a pool of clinicians is available across multiple time zones. Let’s say you’re the Chief Audiologist for the Veterans Administration, supervising over 520 audiologists and hundreds more dispensers and technicians, who dispense 18% of all hearing aids in the United States across six time zones from Maine to Hawai’i, from Florida to Alaska: Telehealth will enable both flex-time and telecommuting for your professional Federal employees, while at the same time speeding access and reducing traveling and lost work time for our Heroes.
Although an unspoken taboo among hearing aid professionals, Telehealth enables one additional patient benefit: Self-programming by tech-savvy patients if they so choose, which we at The Hearing Blog endorse. It is worth reminding the skeptical reader that there are other things besides setting gain, which are suitable to user adjustments, such as noise reduction, anti-feedback, and expansion strength, directional microphone adaptivity, hearing aid mic ↔ DAI/FM mix ratio, and configuring the Music program for maximum enjoyment.
Our friend Elaine Saunders PhD of the aforementioned Blamey & Saunders has a brilliant analogy, comparing self-fit hearing aids to adjusting the temperature of your morning shower:
I can’t understand why hearing aids are usually just fitted to an audiogram. Hearing aids need to work well in everyday sound levels, but typically they are set up to predictions — And there seems to be a whole industry engaged in developing predictions [Editor's note: Dr Saunders is talking about statistically determined fitting prescription models falling into the universal category such as CAM2, DSL-5.0 and NAL-NL2, and those falling into proprietary category from each major hearing aid manufacturer based on their own clinical research and statistical analysis] – which don’t work very well, so that you have to have a highly qualified professional tweak it away from the prediction. It made me think of an analogy with my shower. My shower has a somewhat unintuitive mixer tap. The angle from the wall (tipping the handle towards me) determines the flow, and the rotation of the handle determines the temperature. However, the control for the flow works slightly differently for the hot and the cold. To deal with this in the morning I fiddle with the temperature till the water flow and the temperature are comfortable.
Taking the hearing aid analogy though, I would set up the “cold” to determine what the coldest water temperature that I could tolerate was. Then I would call in a tertiary qualified professional to load in a formula to set up the overall temperature to what it should be (based on overage preferences) then another tertiary qualified person would “tweak” the setting away from the prediction to what I am prepared to use. They might even do some thermometer checks to make sure that my temperature judgements were suitable. Hmmm…
As we somewhat alluded to in the opening paragraph, Telehealth is becoming quite popular in Australia, where except for four densely populated cities many of the remainder of the 22 million people on the continent live far away from their excellent facilities, often necessitating expensive air travel for routine appointments. Australia’s HEARing Cooperative Research Centre (“HEARing CRC”) is actively conducting R&D aimed at improving hearing health delivery to the Outback and nearby Pacific neighbors. From this October 25th 2012 article by HearingCRC:
HEARing CRC Chief Executive Officer, Associate Professor Robert Cowan, said several of the CRC’s research projects have used new technologies to deliver remote hearing healthcare that includes configuring cochlear implants to improve performance (known as MAPping) and undertaking paediatric hearing assessments. “A good example is our Management of Cochlear Implants Using Remote Technologies project which is developing procedures where audiologists can have remote consultations with their patients via the internet. By having such a setup, that includes video conferencing technologies, an individual who has received a cochlear implant can receive follow up device management and habilitation consultations without having to go into the clinic,” Professor Cowan explained.
“One of our Members involved in this project, the University of Queensland, has been effectively using a specialized Australian Telehealth support system called eHAB to work remotely with children between ages of 3 and 12 with cochlear implants. A similar project based at the Sydney Cochlear Implant Centre has had success with providing cochlear implant mapping support to patients located in the pacific nation of Samoa. Preliminary results from this work have shown that 83% out of the 70 clients who had remote consultations were pleased with the outcome.”
Before starting with Telehealth in your own hearing healthcare practice, keep in mind it is very important to carefully select your patients: Although today’s wireless programmers simplify the instrument connections, we do not recommend this for initial fitting of first-time hearing aid users, as these people need guidance on instrument insertion, changing the battery, and in-person counseling; along with hands-on resolution of physical fit issues. We also actively discourage Telehealth for initial fitting of pediatric patients, as this population needs real ear measurements using a probe microphone to compensate for variations in SPL due to widely varying ear canal volumes.
For adult patients, there are two elegant solutions to them not owning an expensive probe mic system: Some instruments from Starkey have a simple adapter that converts the instrument microphone into a probe mic for simple in situ measurements. Also, America Hears, Widex and Cochlear (for the BAHA) have the Sensogram, which is a special channel-based in situ audiometry function in their fitting software, modeled after CI MAPping software: Whereas ReSound Aventa and Starkey Inspire also have in situ audiometer functions, those are based on standard audiogram frequencies with real-ear coupler data (RECD) values “guesstimated” based on entered receiver and earmold venting values. On the other hand, just as T and C/M values are measured in “clinical units” or “charge units” (CU’s) by patient feedback with the MAP being built from these values, hearing aid threshold and UCL values in each channel are measured directly in millivolts delivered to the receiver terminals automatically compensating for any variations of in-situ acoustics; although to keep from freaking out the clinician the fitting software makes an attempt to display the approximate dB levels, even though they are irrelevant to the fitting software building the programs. Put another way, if you can grasp how to MAP a CI, then you should be able to grasp the Widex, America Hears, and Cochlear Sensogram concept. You can watch this video which explains the Sensogram:
One recommendation we can make is – If possible — the patient opens up a video communication channel on a separate device for face-to-face conversations, as opposed to running it on the PC performing the programming (we use an iPod Touch sitting on our laptop; the patient can use any mobile device, tablet, or another webcam-equipped PC): Although Skype will work if the patient is running it on their laptop, the image of you on their screen gets in the way; and also the video window motion bogs down the screen updates.
Another recommendation is that although Aventa will run on an XP PC with 512 mB of RAM, it will be slow: Invest $20 for a 1 or 2 gB DIMM from Egghead.com or Amazon.com:
→ Buy More Memory: It’s Cheaper than Therapy…
Step-by-step instructions for enabling Telehealth for the ReSound Alera and Verso, and Widex Clear, Super and Dream hearing aids
• For ReSound: First, use a fresh install of Aventa 3.4 and very importantly the 126.96.36.1996→188.8.131.522 Patch N4 updater which installs a clean database when operated in standalone mode. [NOTE: If you run Aventa 3.4 in standalone mode, you'll want to temporarily rename the Resound folder to hide it from the Aventa installer since you don't want the patient to see your other patients' data: See two steps below]
• Next, based on extensive discussions with the patient, enter the patient data and the audiogram, click the Aventa button in the upper right corner, connect to the instruments, pre-load four programs into the hearing aids (usually Everyday, Restaurant, Outdoors, and Music), and configure the Unite accessories using Aventa 3.4 in Standalone mode. [Very Important: Do not use a copy linked to NOAH, as you'll need to export the database for the fitting.]
• Copy the Aventa 3.4 software installer, the 184.108.40.2066→220.127.116.112 Patch N4 updater, and .Net 3.5/SP1 standalone installer onto a USB memory stick or DVD to install it on the patient’s own PC. Also, since Aventa will be running in standalone mode on the remote PC, also copy the ReSound folder located in:
as the database is located in:
[NOTE: If you run Aventa 3.4 in standalone mode, you'll want to temporarily rename the Resound folder to hide it from the Aventa installer since don't want the patient to see your other patients' data.]
• Before installing Aventa on an NT5.5 (WinXP or Server 2003) PC, make sure SP3 is applied: You’ll receive a cryptic incompatible OS error message otherwise. Also, check to see if Microsoft .NET Framework 3.5/SP1 and .Net 4.0 are installed: You’ll get a specific error message otherwise. The .NET Framework 3.5/SP1 standalone installer is included in the Aventa package or can be downloaded here; while the .NET Framework 4.0 standalone version is available here;
• Deliver the hearing aids to the patient, and configure their PC by installing Aventa 3.4, and very importantly the 18.104.22.1686→22.214.171.1242 Patch N4 updater; and also copying the
folder with their database;
• For Widex, simply install Compass 5.6; and then separately install the USB driver in the Support.exe file;
• Again, we also recommend setting up a Skype account for them on their iPad or mobile (if possible); if not then on their PC using their webcam (Skype works so much better on a mobile or iPad/pod, or even a second PC, as this separate screen will not cause the main screen to bog down;
• Configure and test remote screen sharing:
• If you’re using Windows Remote Assistance, send a special one kilobyte invitation file, in either Windows XP or Windows 7. For Windows 7:
♣ Start → Help and Support
♣ Click on More support options in the lower left corner
♣ Click on the Windows Remote Assistance link
♣ Click on Invite someone you trust
♣ Save the invitation file to a location you can find
♣ When prompted, copy the password to the clipboard
♣ Compose an e-mail to your account, paste the password into the message and attach the .msincident file. [Note: some POP3 malware/spam filters, including Barracuda, accidentally strip this type of file off the e-mail message. We use a Gmail account to receive and download the message.]
♦ The procedure for Windows XP and Windows Server 2003 is similar, though you need to manually create a password, and also set an invitation expiration time of 30 days;
• If you’re using something else besides MS Remote Assistance, punch a hole in their router firewall (and PC firewall software, if applicable): If you use MS Remote Desktop Protocol, then open up port 3389 to TCP & UDP traffic. More from Microsoft here;
• If for some really odd reason you can’t use port 3389, change it to another using RegEdit. To launch:
Start → Run → regedit.exe
then modify this key:
Here’s Microsoft Knowledge Base article 306759 with the full instructions;
• Alternately, load a copy of the RealVNC lite server, and configure it (usually) to work on TCP port 53, and also open up TCP & UDP port 53 in the router firewall;
• Another alternative is to use LogMeIn Free or Pro: You won’t need to punch a hole in the router to use this, as it tunnels on TCP port 443. [Sydney Cochlear Implant Centre uses LogMeIn software for their Remote MAPping Programme, for what it's worth; however ];
• Install Dynamic DNS and assign a host name: Dynamic DNS runs as a background service allowing me to “find” their PC by hostname, instead of having them manually query the router. You need this if you’re using VNC or Microsoft RDP directly; however it’s Handy for quickly troubleshooting connection & firewall issues for LogMeIn & MS Remote Assistance. Alternately, if their router has Dynamic DNS (many do now), then you can give it a host name; however if you implement dynamic DNS this way, you can’t find their laptop if they take it out in the field for in situ instrument programming;
• Finally, test everything out, and then have the initial face-to-face fitting session; and instruct them on how to use the fitting software if they want the “keys to the car.” Generally, I caution them to leave the gain & compression settings alone (I change them in a remote session); however I instruct them on how to pair accessories, and also tweak the noise reduction, mic zooming settings, and mic on/off when the DAI, TV, Phone Clip and Mini Mic accessories are used: This way if they want to add accessories, they can configure it themselves;
• GN ReSound has several eCademy Aventa training videos the patient can view. [However -- And despite repeated pleas from hearing impaired professionals -- these videos, like most of GN ReSound's video content, are .NOT. captioned.] Also, ReSound has a series of free training webinars and text-based courses on their AudiologyOnline channel.
Now this is how you do Telehealth properly!
- iPhone Attachment Designed for At-Home Diagnoses of Ear Infections: Georgia Tech Newsroom http://www.gatech.edu/newsroom/release.html?nid=155181
- Remotoscope YouTube video: http://www.gatech.edu/newsroom/release.html?nid=155181
- Georgia Tech YouTube channel: http://www.youtube.com/user/GeorgiaTech
- Research shows new technology can deliver hearing health services from afar: HearingCRC news releas http://www.hearnet.org.au/research-shows-new-technology-can-deliver-hearing-health-services-from-afar/
- LogMeIn suite of remote assistance software http://www.LogMeIn.com
- Sydney Cochlear Implant Centre http://www.SCIC.org.au
- Why setting up hearing aids, is like adjusting your shower temperature, by Elaine Saunders PhD http://elainesaunders.com.au/why-setting-up-hearing-aids-is-like-adjusting-your-shower-temperature/
- CAM2 software for hearing aid fitting http://www.enterprise.cam.ac.uk/industry/licensing-opportunities/cam2-software-hearing-aid-fitting/
- Comparison of the CAM2 and NAL-NL2 Hearing Aid Fitting Methods http://www.ncbi.nlm.nih.gov/pubmed/22878351
- DSL (Desired Sensation Level) History http://www.dslio.com/page/en/dsl/history.html
- Widex M-Dex remote control/streamer: http://www.widex.com/en/products/dex/mdex/
- Microsoft .NET 3.5/SP1 standalone installer: http://www.microsoft.com/en-us/download/details.aspx?id=25150
- Microsoft .NET 4.0 standalone installer: http://www.microsoft.com/en-us/download/details.aspx?id=24872
- GN ReSound Aventa fitting software: http://www.resound.com/professionals/fitting
- GN ReSound eCademy uncaptioned training videos: http://www.gnresound.com/professionals/training-and-education/ecademy/aventa-training
- GN ReSound training webinars and text-based courses on AudiologyOnline.com: http://www.audiologyonline.com/expo/resound/
- Our friend who is a deaf audiologist in Toronto got implanted in Germany, and her CI centre gave her the programmer for them to perform remote MAPping.
- Top CI audiologist Bill Shapiro at NYU Langone Medical Center in Manhattan also uses Telehealth in the operating room during CI surgery, performing implant boot-up and diagnostics from his office without having to scrub in.
- There is also preliminary talk in the pediatric auditory brainstem implant (ABI) community that Dr Vittorio Colletti’s audiologist in Verona, Italy will be performing remote ABI MAPping, as most of his infants & toddlers are using Med-El ABI’s, which do (not yet) have FDA approval. Of course, any time an ABI is MAPped it must be closely supervised by a physician with resuscitative gear, in addition to having an audiologist with the patient.
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