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Interview with Barry Freeman, Ph.D., & Harvey Abrams, Ph.D.

Barry A. Freeman, PhD

January 10, 2011
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Topic: Starkey's Innovation in Action Symposium and a New Development from Starkey
CAROLYN SMAKA: Today I have the pleasure of speaking with Barry Freeman and Harvey Abrams. Our topic is Starkey's recent Innovation in Action educational symposium, as well an exciting new development from Starkey.

Barry, as Starkey's Senior Director of Education and Audiology, where did the idea of the Innovation in Action Symposium come from?



BARRY FREEMAN: Over the last several years, Starkey has focused on evidence. Before we make a claim about our products or technology, we have to have the evidence behind the claim and that evidence has to be supported by science and data. Evidence is the foundation for everything we do, and this ensures that patient benefit drives our innovation. We challenge the industry to follow our lead in this regard.

To that end, we've also created a website www.starkeyevidence.com where we post our evidence whether that's peer reviewed publications, benchmarking data, technical papers, internal research and more.

At Starkey, we even have a weekly meeting with our marketing team where we "self-police" if you will;our policy is that no claims are allowed to be made unless we have the evidence to back them up.

The idea for the Innovation in Action Symposium came about as we realized that there still are a lot of people - for example, those teaching classes in universities - who may not be aware of our focus on evidence. We thought a meeting where we present the science and discuss how we have built on scientific evidence to develop our hearing instruments and technology would be a great way to get the information across. Internally we dubbed this meeting "The Science Meeting."

The purpose of the meeting was to introduce people to the science behind our thinking, the research we are doing, and the implementations that come out of that research. So people like Brent Edwards, our Vice President of Research, and Jason Galster would have the opportunity to highlight the research we are doing, both within the company and also the research collaborations with universities and other outside collaborative initiatives.

In addition, we wanted to provide folks the opportunity to hear some dynamite, thought- provoking presentations from people outside of Starkey including Alice Holmes, Arthur Boothroyd, Fan-Gang Zeng and DeWet Swanepoel, and let them know that as a company we support the ideology community.

SMAKA: Evidenced-based practice is more important than ever today.

FREEMAN: Yes, and it's frustrating to us because our focus is on evidence, but that is not the case with all the technologies on the market today. We are the only U.S. manufacturer in the industry and our research and development is based here in the U.S. We also collaborate with universities and research facilities around the globe, as Brent can tell you, and we are always seeking opportunities for new scientific partnerships.

As I mentioned, in addition to presenting our research, we invited experts to the symposium to present their research and to discuss evidence in other relevant areas. For example, Fan-Gang Zeng gave a wonderful presentation about bilateral cochlear implants versus bimodal stimulation and noted that at this point in time, the evidence is lacking to support bilateral cochlear implantation.

SMAKA: That was a fascinating presentation.

FREEMAN: Several weeks ago, we had a Pediatric Symposium here and we had presentations on different types of technology as well. Anu Sharma discussed cognitive processing in children and Harvey Dillon presented his work on adults looking at P1 waves for example.

What's coming out of this research that we all need to keep in mind is that when you're fitting amplification today, you need to carefully consider the evidence behind it. When you're fitting someone with technology or performing surgery today, you need to look at the long-term potential consequences and opportunities, especially with children who will likely live another 80, 90 years or more.

For example, there is emerging evidence about the value of audibility as compared to not stimulating the higher frequencies with technology, as is the case with frequency transposing technology. With brain reorganization, what are the consequences of putting a child in this technology for five or ten years during the critical stages of development? Where is the evidence to say that it is appropriate and what will be the consequences to the child's auditory system 20 years from now when new technology may be available to stimulate or regenerate those areas that have never been stimulated?

These are the kinds of important questions that need to be asked. Our point being that there needs to be evidence behind what we're doing as a profession as a whole.

SMAKA: What was interesting to me was sitting in a room with a group of people from university and research settings, and the amazing amount of brainstorming and information sharing that went on during the question and answer period.

FREEMAN: I agree, it was great! Our staff kept saying, "Wow, this is dynamite. We've never heard these kinds of discussions before." The ideas, insight and information that came out of the group were very exciting. This is a group that will be mentoring the future of the profession, and we have a lot to offer them.

SMAKA: You know, I'd heard about teleaudiology before the symposium but I was always thinking of my own backyard, i.e. "How would I use this in my practice?" To hear about the implications for developing countries from DeWet Swanepoel gave me a totally different perspective.

FREEMAN: I was so pleased DeWet came and presented on this topic. His group is doing great work and their data never ceases to amaze me. He talks about 500 babies a day being born in Africa with hearing loss. I don't know if you caught that number but it absolutely blew me away.

DeWet showed how we can use some of the new technologies that are available remotely to help manage patients in a cost effective manner.

Starkey is the first company that has moved into the area of teleaudiology with our technology. We also presented at AudiologyNOW! on the topic, and I have a paper on teleaudiology coming up at the American Telemedicine Association next spring.

Think of the patient who can't get a ride to the audiologist from the assistive care facility, the patient who can't take another day off from work right away, or the patient who can't get a babysitter - and they're having a minor problem with their hearing aids. With our technology, the person just holds the telephone next to the ear and the professional can make minor adjustments on that hearing aid. It's an interim type of move to help the patient before they can get in for a more complete adjustment.

It's cutting edge, but we're still just touching the surface of the opportunities with teleaudiology.

SMAKA: I talked to DeWet about the fear that teleaudiology means audiology is being taken away from audiologists. I'm paraphrasing but he said something like, "We have to own teleaudiology. If we own it, it will continue to be ours but we need to get in now at the ground level and move it forward".

FREEMAN: I've personally been doing a lot of work on demographics in the profession, and looking at growth and the future. It's clear from the data that there will be no growth in the audiology profession over the next couple of decades. The universities are not graduating enough people to replace those that are hitting retirement age. The demand is increasing and there is a real concern about an unmet need for audiology services in the future.

We need to deal now with issues like efficiencies in the way we deliver services, and how to deliver services in a more cost-effective manner. I am a supporter of the role of audiology assistants. Does it require an Au.D. to take ear impressions, fill out a form, put them in a box, and put the FedEx label on it;or could that be done by a trained assistant? We need to look at all of our processes from evaluation through management. We cannot keep doing things the same way that we've always done them. We don't want someone else stepping in and taking over our scope of practice because we can't meet the demand in the future.

SMAKA: The Symposium seemed to take a "big picture" approach at our profession in where we're going.

FREEMAN: That certainly was our intent. We know the attendees aren't people that are out selling hearing aids;that wasn't the purpose of the Symposium. Instead, we wanted to look to the future and bring forth some important areas that will impact the profession. The university folks are the ones shaping our future through students, and it's important that we reach out to them, show them what we have to offer and the direction we're going in, and whenever possible, develop collaborations with them.

SMAKA: Thanks so much, Barry.

FREEMAN: Thanks for having me.

SMAKA: Harvey, before we get into the technology you talked about at the Symposium, how are you enjoying your role as Director of Audiology Research at Starkey?

HARVEY ABRAMS: I'm enjoying it immensely. As you may know, I spent about 37 years or so in government, mostly at the VA, but also with the Department of Defense, both as active duty, Army, and then as a Department of Army civilian at Walter Reed.

When Brent Edwards approached me about this position at Starkey, he introduced a new technology they were working on called Subjective Space. Then we talked about other research at Starkey, facilities, etc. and when he offered me the position, I said "You had me at Subjective Space."

[laughter]

SMAKA: That's great.

ABRAMS: When I saw this technology, which we are now calling SoundPoint, I knew it was something I really wanted to be a part of, because I felt that it would be a major game changer in the way we optimize the hearing aid fitting.

SoundPoint allows the patient , within certain constraints, to adjust the hearing aid parameters in a way that will likely yield the best outcomes in terms of both their preferred settings and in terms of audibility.

Things have been moving in this direction, as you know Carolyn. There've been recent attempts at automatically adjusting the hearing aid settings through, for example, trainable hearing aids. We understand that the settings we first provide patients with when we initially fit the hearing aid may not necessarily be the settings that they ultimately prefer.

With our technology, we're kind of skipping that step, and providing the wearers with the opportunity to set their preferred parameters "out-of-the-box."

SMAKA: Why did you think SoundPoint was such an important technology at the get- go?

ABRAMS: I think you have to place SoundPoint in an historical perspective. Early on, hearing aids were very simple devices and we had very little means of adjusting them. Later on, analog devices allowed more clinician control through the use of potentiometers although the adjustment of compression characteristics was limited.

Today, hearing aids are amazingly sophisticated. Despite the programming flexibility we have at our disposal as clinicians, there are multiple signal processing interactions occurring in the background that we can't control and perhaps don't even want to control. The complexity of today's technology has outpaced the clinician's ability to make adjustments to that technology simply because there are too many interactions happening in the background.

With probe microphone instrumentation, we have an objective and evidenced-based methodology for fitting hearing aids.;as we make changes to the hearing instrument parameters we can see what impact it's having in the ear, but only to a certain extent.

Yet despite the advances in hearing aid technology and fitting techniques, patients don't always achieve the best possible outcome, even if we provide the best technology available, and we verify the fitting.

SMAKA: You had mentioned that SoundPoint enables the patient to adjust the instruments within some controlled parameters. So, after using SoundPoint, they won't end up 25 dB below the target that you fit them to and verified?

ABRAMS: No, they won't. The starting point is the initial or default setting based on their audiogram and fitting algorithm. They navigate from that point within certain constraints, so they can't select a set of parameters that are going to be inappropriate for their hearing loss.

SMAKA: I can understand how patients going through a self-tuning process would end up with something that they think subjectively sounds better, and your data support this. What surprised me was that your data also show they have improved audibility after this process.

ABRAMS: Right. The data indicated that audibility was better than what was achieved for the default, initial fitting and at least as good as what was achieved for the audiologist-adjusted fitting That was a very gratifying finding, because in the end, audibility is what fitting hearing aids is all about. When I teach hearing aids to students, I tell them that all the sophistication and complexity in hearing aids - such as multiband compression, feedback cancellation circuits and noise reduction algorithms, etc. - does not mean anything unless the speech signal is audible.

To paraphrase the real estate industry, the three most important factors in fitting hearing aids are audibility, audibility, audibility. Of course, you also need to ensure that you're not creating a situation where loud sounds are going to be uncomfortable, but that also can be controlled through SoundPoint.

SMAKA: I happen to be a control freak. Are there people like me who may think, "Okay, I know what I'm doing when I set hearing instruments to evidence-based targets and verify that. I'm using best practices in my clinic. With this technology, I'm just kind of turning things over to the patient."

ABRAMS: Well, that's a reasonable concern. For those clinicians who feel they are already getting excellent outcomes SoundPoint can serve as another option in their toolbox. It doesn't need to replace anything that they're currently doing. In addition, this technique may not be appropriate for first time hearing aid users as they have no frame of reference for amplified speech.

Clinicians may find a particular value in this approach for select patients who return to their clinic expressing dissatisfaction with the quality of the instrument or its performance in certain situations. Often our patients have difficulty expressing the difficulties they're experiencing;for these patients, the audiologist can use SoundPoint to help resolve the complaints and optimize the fitting. . We know from healthcare literature that when an individual feels that they're actually a participant and helping to make decisions in terms of their care, they tend to be more satisfied with the outcomes. SoundPoint gets the patient involved and participating in their care.

SMAKA: I would also think that for patients like musicians who are very particular and sophisticated listeners, this could be especially helpful.

ABRAMS: You bring up a good point in terms of settings for music.

We have a fairly good research base in terms of how to adjust the incoming signal for maximizing speech intelligibility. We have a well-defined, well-researched ANSI standard for calculating the Speech Intelligibility Index. We can reasonably predict intelligibility on the basis of how much of the speech signal is audible to the individual. There is considerable empirical evidence upon which our prescriptive formulas are based and we have an impressive research foundation that helps to inform us as far as fitting hearing aids for speech understanding is concerned.

In contrast, where is the research that helps to inform us as to how to best adjust the hearing aid for maximum music perception and appreciation? Professional musicians present a particular problem, because current hearing aids, no matter how good they may be, tend to distort music. For professional musicians, that may be the difference between being able to continue working or having to give it up. I've known several musicians who essentially had to give up their musical careers, because music sounded so terrible to them, even through state-of-the-art hearing aids, and I simply couldn't adjust the hearing instruments to their satisfaction.

We know that music is perceived differently by different people, and it can be entirely independent of one's hearing loss. Music perception may be attributed to other variables, like the kind of music you listen to. There are some people, like myself, who just love to listen to music very loudly. My wife gets into the car after I've been driving, and she can't believe how high the volume is set. . Why do some people enjoy loud music , but they can't tolerate loud speech? There is something uniquely personal about the music listening experience. There's a significant emotional component;it creates different feelings in us depending on the situation, and it can be evocative of past experiences. It can excite us. It can depress us. It can move us.

How do you create a single prescription for a music program or establish offsets from the "speech in quiet" program to account for all of the different factors associated with music listening? I maintain you can't, and I maintain that music listening is so unique to each individual that the only way to achieve music listening satisfaction for many of our patients is to allow them to adjust their own settings.

SMAKA: Music is not something I've specifically asked about unless the patient brought it up.

ABRAMS: Sure. We typically don't. In most cases our primary goal is to improve speech understanding and if that's achieved, we're satisfied with the results. Even if we think to ask our patient about music listening we don't necessarily spend the necessary amount of time to fine-tune the hearing aid settings for music. SoundPoint may provide the clinician a quick and effective means to optimize the music listening experience for our patients..

SMAKA: What other future uses do you foresee for this technology?

ABRAMS: How about tinnitus treatment? I can see the use of SoundPoint technology to help patients adjust the response of the hearing aid, sound generator, or sound conditioning stimulus for more effective tinnitus management.
My ultimate vision is having SoundPoint installed as an application on a smart phone. Imagine, you're in a noisy restaurant, and you're having difficulty communicating. You take out your smart phone, tap on the SoundPoint app, and you wirelessly adjust your hearing aid settings, which not only modifies the gain, frequency and compression characteristics, but also the directional microphone polarity, the aggressiveness of the noise reduction algorithm, and the ear-to-ear settings, until you achieve your best possible understanding and comfort.. You tap the screen again to store the settings in your hearing aid and create a preset in the app, which you can retrieve when you're in a similar environment in the future.

SMAKA: All these technologies are eventually going to converge.

ABRAMS: Yes. We're seeing significant convergence of consumer electronics and healthcare products which is particularly evident in the increased utilization of wireless technology throughout the hearing aid industry. We're going to see continued improvements in our wireless products over the next couple of years as well as improvements in our environmental classification, compression, noise reduction and directional technologies and algorithms With SoundPoint, we hope to have an optimization tool that will enable all of those features to work together more effectively while permitting the patients to participate in the adjustment of their own devices.

SMAKA: Harvey, since SoundPoint isn't scheduled to be released until later this year, I am going to restrain from asking questions like when will it be available, what instruments will it be compatible with and so forth. But I really appreciate you giving us the overview.

ABRAMS: Thank you, Carolyn. As you can tell, I'm very enthusiastic about SoundPoint and I enjoyed speaking with you about it.

For more information about Starkey, please visit www.starkey.com or the Starkey Web Channel on AudiologyOnline.
2019 NIHL Series | 4 advanced-level live webinars | June 5, 12, 19, + 26 | 12:00 pm EDT | Guest Editor: Brian J. Fligor, ScD, PA


barry a freeman

Barry A. Freeman, PhD

President, Audiology Consultants, Ft. Lauderdale, FL

Barry A. Freeman is President and CEO of Audiology Consultants, Ft. Lauderdale, FL.  Most recently, he was Senior Director of Audiology and Education for Starkey, Inc.  Prior to joining Starkey, he was Chair and Professor in the Audiology Department in the Health Professions Division at Nova Southeastern University, Ft. Lauderdale, Florida. Dr. Freeman earned his Bachelor’s degree in business and economics from Boston University, a Master’s in audiology, and his Ph.D. in Auditory Science from Michigan State University.  Dr. Freeman has taught audiology at several universities including Syracuse, Vanderbilt, Gallaudet, University of South Florida, and Nova Southeastern. Prior to joining NSU, Dr. Freeman was in private practice for twenty years at the Center for Audiology in Clarksville, Tennessee. Dr. Freeman has more than 50 published journal articles, several book chapters, one book plus more than 300 professional presentations at national and international meetings.  He was president of the American Academy of Audiology in 1996-97 and served on the Academy’s Board of Directors for six years.  He continues to serve on professional committees including the Advisory Board of the Accreditation Commission for Audiology Education.  He received the Distinguished Achievement Award from the American Academy in 2006.