Toward New Software Goals: Delighting Patients with Interactivity

It’s his 14th birthday, and your teenage son is exhilarated, exhausted, but still exclaiming, “Wow, that is so cool!” He has just spent the day on the new computer game you gave him—a 3D extravaganza of sight, sound, and action that has captivated him for the past 10 hours.

The challenge before us is to achieve even a fraction of such positive energy with a computer application as mundane as programming a hearing aid. Right now you’re saying, “You’ve got to be kidding me.” But bear with us. While a gamer’s level of enthusiasm is unrealistic, perhaps we can achieve at least a glimmer of that attitude with the software capabilities used to program modern hearing instruments.

Recent developments in digital hearing aids and their fitting systems parallel the growing role that software and firmware play in many consumer products and services, such as computers, cell phones, navigation devices, games, toys, ATMs, grocery stores, the Internet, e-mail, and medical monitoring, to name just a few. Digital functionality has become so integrated into our everyday lives that we hardly even notice anymore.

Along with the penetration of software-driven products, the expectations of consumers have been elevated. Indeed, the mind-set of sophisticated consumers is that technology advances rapidly; they expect things to keep improving, and the hearing aid manufacturing and dispensing communities are expected to meet that challenge.

Hearing instrument programming software has risen to a higher plane in recent years, and today’s software differentiates products and manufacturers, based on both the benefits it yields and the impression it creates. Software is no longer just a fancy screwdriver. It has the potential to affect not only the operation and benefits of hearing aids, but also the mind-set of the person wearing those hearing aids and the dispensing professional fitting them. It must combine scientific rigor with engineering elegance and an eye to design. Software has the potential to delight.

This article will outline the basic job requirements of hearing aid programming software and then illustrate how software can exceed those expectations. Readers interested in some of the history leading up to current developments are referred to the sidebar.

Basic Goals of a Hearing Aid Fitting

The basic goals of a hearing aid fitting include audibility, intelligibility, comfort, good sound quality, and ultimately wearer satisfaction.

Audibility across the required frequency range is the starting point for any hearing aid fitting. Along with audibility, we can also expect improved speech intelligibility. While good audibility may compromise comfort, simply because both signal and noise become audible, modern noise control algorithms have the potential to maintain comfort over a widening range of input levels and noise types. Good sound quality, as judged by the wearer, may not always accompany audibility, but modern instruments can balance these sometimes disparate goals better than ever. Ultimately, if the combination of these factors adds up to patient satisfaction, patients will hopefully keep the instruments in their ears, not in a drawer.

Beyond the Basics of Software Goals

While software control of hearing aid operation is essential and widely re­ported,^1-7 adjustment of the hearing aid per se is not the topic of this paper. Instead of the usual discussion of what the hearing aid can do, we will focus on what software can do beyond the fitting.

We are setting forth a more challenging goal: instead of just satisfying a patient, let’s aim to delight that patient. And, while we’re at it, let’s delight the hearing care professional as well.

If we asked you to list the things you look for in selecting hearing aid programming software, beyond the basic fitting adjustments, you could create a long list. It may be possible to condense this wish list into the following five categories of goals:

1. Maximize efficiency.
2. Provide objective data to guide hearing aid adjustments.
3. Optimize the use of technology, while minimizing workload.
4. Build patient confidence.
5. Assist in patient counseling.

To illustrate how modern software achieves these goals, the following sections sample some of the features of Starkey’s Inspire OS software system. Attached to each heading is a list identifying which of the above goals each feature supports. This is not an exhaustive discussion of Inspire OS features; rather, it highlights the stars in the software cast, with an occasional brief mention of some of the vital supporting players working behind the scenes.

Manufacturers competing in the current hearing instrument market have done an admirable job of designing excellent software. The examples we are using here are just that: examples. Although we hold the competitive systems in high regard, a thorough review and comparison of all software features are beyond the current scope (and space requirements) of this article.

Software development is not a small task. To make the Inspire OS platform, 25 people worked for 24 months, creating more than a million lines of software code. A sampling of their achievements will be presented here (to see an interesting e-mail string about the development of the software, read the “Software Magnitude and Milestones” sidebar at the end of this article).

Evidence-based Software Development

In recent years, a high level of importance has been placed on evidence-based approaches to product development, an approach that applies equally to creating hearing instruments and to creating software to support those instruments.^8-11

FIGURE 1. Multi-Function Slider in Inspire OS software controls many variables in a confined space, requiring minimal cursor movement.

Evidence-based design principles have been used in the development of the Inspire OS software platform, and in this case the evidence consisted of what hearing professionals want and need. A customer request list of features and functionality was regularly generated, updated, and reviewed. Several customer surveys, internal focus groups, and cross-functional review teams, consisting of audiologists and engineers, all provided input before and during the software development process. Progress was monitored through customer focus groups using prototype software and direct observation of customers using the software in their offices and at Starkey.

The result of these data collection and development efforts is a software package embodying features that are designed to be meaningful and desirable, not frivolous or idiosyncratic. Fitting software must offer flexibility that is powerful, yet not overwhelming. Ultimately, the software should reflect the practical priorities of the professionals who are using it. Those priorities include speed, ease of use, and a logical flow from one operation to the next. Much of the software fine-structure in Inspire OS aims to achieve these goals, such as a Navigation Panel to select features and operations and a nearly instantaneous read/write capability.

One example that deserves special mention is Inspire’s slider controls (Figure 1). From a human interface perspective, anything that reduces the number and length of cursor movements will improve efficiency. A Multi-Function Slider in Inspire OS maximizes the efficiency of adjusting several parameters—overall channel gain, channel gain for high input levels, channel gain for low input levels, and compression ratios, in one or both ears—by containing them in a small space that requires minimal cursor movement. The slider expands when the cursor hovers over it, changing from the view on the left of the figure to that on the right.

FIGURE 2. Measured real-ear responses displayed on Inspire OS software screen. Graphs show responses to 50 (blue), 70 (green), and 90 (purple) dB SPL inputs. The dashed black line represents the maximum output of the instrument.

Integrated real-ear measurements and speech mapping (Goals addressed: 1-5). Any hearing professional who adheres to principles of evidence-based practice appreciates objective data about hearing aid operation. The Integrated Real-Ear Measurement capability of the Destiny 1600 provides an accurate model of the hearing aid’s real-ear aided response (REAR). By measuring the real-ear coupler difference (RECD) through the hearing aid in the patient’s ear, which takes only seconds, the software calculates a more accurate model of the REAR (Figure 2) for this individual’s ear, rather than for a hypothetical average ear.7 The Integrated REM in Destiny 1600 not only offers objective data (goal #2) but does so rapidly (goal #1) and with minimal effort (goal #3).

FIGURE 3. Speech Mapping shows the real-time responses to live speech (black line is patient’s hearing thresholds in dB SPL; purple is real-time input to hearing aid; pink is real-time hearing aid output; thin green line is prescriptive target output for a 70-dB SPL input; bold green line is hearing aid response matching target).

The Speech Mapping feature (formerly SoundView) generates a graphic display of the hearing aid response to any live input. In a typical scenario, one might ask a family member to speak. The acoustic characteristics of that voice at the input and the output of the hearing aid are viewed on screen in real time (Figure 3) and may be compared with the patient’s hearing thresholds or prescriptive targets. Speech Mapping helps a patient and family understand the nature of the hearing loss and the function of hearing aids (goal #5) and build their confidence in the technology (goal #4). When used with the custom RECD of a Destiny 1600, Speech Mapping displays the hearing aid output calibrated in each patient’s ear.

Datalogging (Goals addressed: 1, 2, 4, 5). When you ask patients at a follow-up visit how their new hearing aids have been performing for the past 2 weeks, the information you get back is vague at best. Most modern hearing instruments have some form of datalogging capability to objectify such reports.

The Data Log in the Destiny instrument and Inspire OS software (Figure 4), for example, quantifies the acoustic environment in which the patient is using the instruments (input levels, percent of time in different acoustic environments) and the ways in which the patient uses the instruments (use time, average VC setting, percent of time in different memories). Furthermore, if the Data Log sees an opportunity to improve patient benefit by adjusting any of the software presets in the aid, it will offer recommendations to the operator in the Data Log report. This tool can transform the hearing professional’s decision-making from dependence on subjective reporting and guesswork to a data-based decision-making process.

FIGURE 4. Sample Data Log report for a Destiny 1600 hearing instrument.

Self-diagnosis (Goals addressed: 1, 2, 3). The Self Check feature in the Destiny 1600 provides self-diagnosis of the integrity of the hearing aid microphone, receiver, and circuit. A baseline measurement at the time of the fitting establishes a performance reference, and subsequent diagnostic measurements check component integrity relative to that baseline.

The software displays the Self Check results on screen (Figure 5) when the hearing aid is attached to a programming cable. Alternatively, the hearing professional can enable a patient-run Self Check option, which presents an acoustic signal through the hearing aid to indicate when the instrument needs attention. Activating this option (only recommended with select patients) adds goal 4, building patient confidence, to the list of benefits.

FIGURE 5. Self Check screen display, showing integrity of microphone, circuit, and receiver.

Voice indicators (Goals addressed: 3, 5). Some software can program a hearing aid to emit a tone in order to signal a variety of conditions: low battery, program change, target volume setting, etc. Replacing those tones with speech signals, an option in the Destiny 1600, improves the clarity of the message, reduces reliance on the patient’s memory, and builds patient confidence in their handling of the instrument.

For adjustment and demonstration purposes, Inspire OS calls up graphic icons representing the indicators on an audiogram displaying patient thresholds. Clicking the icon plays a sample of the Indicator through the hearing aid for the patient and through the PC speakers for the spouse or significant other. An added bonus is the extensive array of voice options—more than 20 languages with both male and female voices.

Environmental simulations and demonstrations (Goals addressed: 2, 4, 5). Realistic demonstrations can improve a patient’s understanding of what hearing aids can do and how to use them. Surround Town, for example, is an acoustic virtual reality, created by the Inspire OS software and presented through a 5.1 surround sound system. It lets the operator control a variety of sound sources in several different environments (Figure 6) to demonstrate specific hearing aid features.

Instead of just hearing instructions from the hearing care professional, the patient experiences the benefits of proper hearing aid use and communication strategies aurally and visually, as if they were actually in different acoustic environments. In some cases, it allows the professional to recreate a problematic situation to pinpoint the source of a complaint.

FIGURE 6. Example of one acoustic environment created by Surround Town. The hearing aid wearer’s virtual position (the green figure in the middle) and a variety of sound sources can be changed to simulate this outdoor situation.

Hearing loss simulators (Goals 4, 5). Hearing loss simulators can help patients and families understand the implications of a hearing loss, an important goal in hearing rehabilitation. The Hearing Loss Simulator in Inspire OS, scheduled for release in spring of 2008, will simulate any degree and shape of hearing loss, including that of the patient. The dispensing professional can activate a number of real-world sounds to be heard through the simulated loss, with each sound represented on a customizable three-dimensional display. Family members listening to these simulations gain insight into the patient’s auditory experience, an important factor in helping them participate fully in the rehabilitative effort.

Automatic tasking (Goals addressed: 1, 3). With so many new features in modern instruments, hearing care professionals are tasked with managing numerous steps to ensure their full utility. In the case of the Destiny 1600, for example, at the time of the fitting, to gain maximum benefit from the technology, a hearing professional must run the Integrated Real-Ear calibration, initialize the Active Feedback Intercept, perform a Best Fit based on the patient’s audiogram, set the Self Check baseline, reset the Data Log, perform verification with Speech Mapping, and set programmed Reminders. These tasks are added, of course, to other time-consuming steps of talking to the patient about hearing aid features, ensuring that basic fitting goals are achieved, completing paperwork, counseling patient and family on hearing aid use and communication strategies, and so on.

“The Accuracy and Clinical Usefulness of Manufacturer-Predicted REAR Values in Adult Hearing Aid Fittings,” by Nancy L. Aarts, PhD, and Carrie S. Caffee, MS. November 2005 HR Archives. “How to Use Live Speech Mapping as Part of a Hearing Instrument Fitting and Verification Protocol,” by Terry Ross and Kenneth E. Smith, PhD. June 2005 HR Archives.

To streamline the process and ensure that no steps are missed, Inspire OS offers a protocol called Auto Path, which automatically executes all six of these steps in logical order, prompting the hearing care professional as needed until completion. It does all of this in 90 seconds (binaurally) and guarantees that no steps are missed along the way. Professionals using Auto Path have reported reduction in time needed to complete an initial fitting, leaving more time for patient counseling.

Summary

Fitting software programs hearing aids better than ever before. But that’s not all it does. Modern software has great potential to improve efficiency, guide fitting adjustments with objective data, maximize technology while minimizing workload, build patient confidence, and assist in patient counseling. It also combines rigorous scientific algorithms with efficient, elegant design, and a dedication to improving patient counseling and increasing confidence.

Speed, ease, and usability are essential to the video game operator we met at the beginning of the article. The gamer would not think of using software that slowed the action. Now, with modern hearing aid programming software, there is likewise no reason for hearing care professionals to operate without these same benefits.

This article has described only a few examples of software features that approach these goals, and the authors have attempted to place them into an historical perspective. The motivated hearing care professional will continue to monitor the expanding array of applications to improve the patient experience and resulting benefits. And keep an ear out for that call from the fitting room, in the voice of either a hearing professional or a patient, “Oh, wow, that’s so cool!”

References

1. Yanz JL, Olson L. Open-ear fittings: an entry into hearing care for mild losses. Hearing Review. 2006;13(2):48-52.
2. Merks I, Banerjee S, Trine T. Assessing the effectiveness of feedback cancellers in hearing aids. Hearing Review. 2006;13(4):53-57.
3. Howes C, Olson L. The role of virtual reality in hearing instrument fittings. Hearing Review. 2006;13(5):60-63.
4. Banerjee S, Recker K, Paumen A. A tale of two feedback cancellers. Hearing Review. 2006;13(7):40-44.
5. Olson L, Pisa J. Large-scale beta clinical trial of a new hearing aid system. Hearing Review. 2006;13(10):50-56.
6. Banerjee S, Olson L, Recker K, Pisa J. Efficacy and effectiveness of a pattern-recognition algorithm. Hear Jour. 2006;59:10:34-41.
7. Yanz JL, Pisa JFD, Olson L. Integrated REM: real-ear measurement from a hearing aid. Hearing Review. 2007;14(5):44-51.
8. Bentler R, Eiler C, Hornsby B, Moodie ST, Olson L, Valente M. Practical approaches to evidence-based practice. Hearing Review. 2007;14(6):36-41.
9. Yanz JL. Panelists challenge “conventional wisdoms” on hearing aid design. Hear Jour. 2006;59(3):36-44.
10. Bentler RA, Yanz JL. Hearing aid manufacturers’ panel to discuss evidence-based design. The HJ AudiologyNOW! Special Edition. April 2007.
11. Cox R, et al. Special Issue: Evidence-based Practice in Audiology. J Amer Acad Audiol. 2005;16(7):410-522.
12. Vonlanthen A, Arndt H. Hearing Instrument Technology for the Hearing Healthcare Professional. Clifton Park, NY: Delmar; 1995:125-129.
13. Preves D. Digital Signal Processing for Hearing Aids. Livonia, Mich: International Hearing Society; 2006:2, 8-9.
14. Moore GA. Crossing the Chasm: Marketing and Selling Disruptive Products to Mainstream Customers. New York City: Harper Business Essentials; 2002.
15. Yanz J, Preves D. Assessing the feasibility of Bluetooth in hearing rehabilitation. Hear Jour. 2007;60(11):52-60.

---

This article was submitted to HR by Jerry Yanz, PhD, senior staff audiologist; David Preves, PhD, senior staff engineer; and Christopher Howes, product manager of fitting software, at Starkey Laboratories, Eden Prairie, Minn. Correspondence can be addressed to [email protected] or Jerry Yanz, PhD, Starkey Laboratories Inc, 6700 Washington Ave S, Minneapolis, MN 55344; e-mail: .