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Using Automated Technology and Telehealth for Adults With Mild to Moderate Hearing Loss

November 2010

Mark Krumm, PhD, CCC-A

In August of 2009, the National Institute on Deafness and Other Communication Disorders (NIDCD) conducted a 2-day meeting to discuss the identification and rehabilitation of adults with mild to moderate forms of hearing loss (NIDCD, 2009). The purpose was to develop a research agenda to increase the accessibility and affordability of hearing health care for adults with mild to moderate hearing loss using innovative and creative solutions for implementation, including accessible and low-cost hearing aids. Most hearing aid users have lived with hearing loss for over 10 years, and their impairments typically progress to moderate-to-severe levels before they seek a hearing aid (Davis, Smith, Ferguson, Stephens, & Gianopoulos, 2007).

One method discussed at the NIDCD meeting was phone-based hearing screening systems, which have already been tested in Europe and Australia. Also discussed was developing specialized hearing services for high-traffic locations such as malls as well as augmenting the services provided by "minute" clinics found in pharmacies and grocery stores. Added services could include some form of hearing assessment and possibly fitting low-gain hearing aids (using open fit molds).

While audiologists may find these ideas controversial, alternative marketing strategies could increase client flow to the clinics of audiologists over time. Whether this is true can be argued, but audiologists generally agree that many people with hearing loss are not receiving needed services. The barriers leading to a lack of hearing services are often complex. However, better access, lower costs, and convenience may promote increased opportunities for more adults with hearing loss to seek hearing health care.

Home-Based Hearing Screening

As detailed in various journal articles and Internet sources describing home-based hearing screening, most of the screening systems incorporate pure-tone audiometry systems made for personal computer (PC) use or questionnaires. Unfortunately, the pure-tone procedures appear to suffer from questionable calibration, poor validation, and lack of control over environmental noise levels. In addition, researchers have not determined what people do with their hearing results after completing home hearing screening. This issue is a concern because most hearing screening programs do not provide information for further follow-up. The absence of this information likely contributes to poor continuity of services.

Phone-Based Systems

Use of phone technology for hearing screening may be one way to ameliorate calibration issues and reduce the effects of background noise. Specifically, speech-in-noise tasks have promise for screening large numbers of people.

Smits, Kapteyn, and Houtgast (2004) were some of the first investigators to utilize speech-in-noise stimuli for phone-based hearing screening systems. This paradigm was used by Smits et al. because noise is frequently handicapping for individuals with hearing loss and is a good predictor of hearing impairment. In addition, speech-in-noise procedures are administered at a comfortable loudness level above minimal household noise. Therefore, a speech-in-noise test could be conducted without the calibration and noise issues associated with pure-tone audiometry. The results of Smits et al.'s study, conducted on more than 65,000 Dutch citizens, indicated that this task was valid and capable of generating interest in large numbers of people concerned with hearing loss.

This same paradigm was the basis of studies in England and in Australia. Harvey Dillon, Director of Research at the National Acoustic Laboratories, Sydney, Australia, while presenting information at the 2009 NIDCD working group meeting, suggested that the telephone screening system used in Australia was effective. He did note, however, that advertisement was necessary to alert people concerning this system. One innovation of the Australian phone screening model was that it provided for continuity of services. Specifically, when individuals would yield results consistent with hearing loss, these individuals were directed via automated phone services to local practitioners for follow-up.

Robust telephone hearing screening programs are functioning in the Netherlands, England, Australia, and France, and have moved from research projects to become a component of the national hearing health care system. I am encouraged by the use of phone-based hearing screening programs that employ speech-in-noise paradigms because they appear to overcome many problems of validity associated with pure-tone testing over the phone. My hope is that similar technology will also become available in the United States on a widespread basis in the immediate future after, of course, appropriate validation.

Cell Phones and Hearing Screening

A substantial number of hearing screening programs have been developed for cell phones. Although most of these programs suffer from the same problems found with PCs, one program created by Unitron, a hearing aid manufacturer, has taken advantage of the iPhone platform. Given that the iPhone is greatly popular and the earphones typically worn by i-Phone users are also worn by hearing aid users, calibration issues appear to be less problematic. Downloaded onto the iPhone, the Unitron program called "uHear" provides pure-tone and speech-in-noise screening. In addition, a self-assessment questionnaire is included. The application is free and has received more than 8,500 reviews, which have been generally positive. The application can be found on Unitron's website or through the online iTunes store. To my knowledge, however, this system has not been systematically validated and therefore cannot be recommended at this time.

Providing Greater Public Access for Services

If visibility and convenience are important to increasing the consumer impact of hearing services, audiologists will probably need a greater public presence. The problem is how to expand audiology services into more locations. In all likelihood, audiologists would have to work longer hours, hire additional staff, or augment services through technology. So audiologists might consider cross-disciplinary training of health care personnel at store-based health clinics, as well as automated testing and, in some circumstances, telehealth technology.

Cross-disciplinary training. As a means to extend the reach of audiology practitioners, support personnel could be trained to conduct basic hearing services in addition to what they already do in a pharmacy- or store-based health clinic. The degree of training would depend on the demands of equipment knowledge and difficulty of hearing aid selection and fitting.

Automated testing. Automated testing or self-testing could be used to identify, and perhaps assess, individuals with hearing loss. Self-testing with an intelligent automated system could offer accurate results and measure background noise to ensure validity. Such systems are difficult to find, but there are working prototypes available. One example developed by Margolis, Glasberg, Creeke, and Moore (2010) is called the Automated Method for Testing Auditory Sensitivity (AMTAS). A description of this system can be found on Audiology Incorporated's website. Of course readers are probably familiar to some degree with the Tympany Otogram, which has been sold commercially and provides a broad range of audiometric procedures.

Telehealth applications in audiology (tele-audiology). Telehealth may create some solutions for audiologists working in traditional and nontraditional clinic sites in the same practice. While self-screening at the nontraditional sites could be used to assess many consumers, at least some of these individuals will require more sophisticated testing. Telehealth could be used to evaluate these individuals through remote testing without great disruption to an audiology practice; that is, through telehealth technology, the audiologist could be working in the clinic and simultaneously be "on call" for the provision of more complex audiologic services.

One very interesting system is an audiometer developed by GeoAxon particularly for telehealth applications. This system incorporates sound-treated headphones to minimize noise and provides ongoing measurements of noise levels inside the headphones. This system was described by Swanepoel, Koekemoer, and Clark (2010), and some screen captures of this system are available on Tele-Audiology Network's website. An innovative web-based audiometer has also been described by Yao, Givens, and Wan (2009). Although studies reporting complete evaluations have not been described yet, it is likely that telehealth test systems will be able to do all basic evaluation tasks. In addition, telehealth can be effective via store-and-forward technology, in which recorded data (such as audiograms, tympanograms, and video-otoscopy images) are sent via e-mail or fax to an audiologist for interpretation if test results require review.

Testing in Nontraditional Settings

If hearing screening or testing is conducted in a highly visible but nontraditional setting (such as a mall), then a number of factors must be considered. Environmental noise must be abated either through environmental or headphone solutions. Preferably, the audiometer would be able to measure the noise fluctuations in the environment and plot the noise floor on the audiogram to assure validity of test results. Audiometers would ideally have both automated self-test and telehealth program capabilities. Video-otoscopy would be desirable to capture the images for later consultation or via telehealth technology. Referrals to appropriate health care professionals appear to be a key to attaining continuity of services.

Hearing Aid Fittings in Nontraditional Settings

On a recent visit to the Middle East, I noticed in a downtown pharmacy that a major manufacturer's hearing aid was being sold. It was in a lovely showcase, and the price was clearly printed by the product. The pharmacist's idea was that people would come in to the store, see the hearing aid, and purchase it with an open mold fitting. The hearing aid was not particularly expensive, at least for the local population. The pharmacy owner was providing hearing aids that were accessible, affordable, and in a highly visible area (in a walking mall). This same concept may work in the United States as a means to encourage people with mild to moderate losses to try amplification earlier than the decade they now wait. Even so, the following issues will require consideration: personnel credentials, test protocols, hearing fitting, troubleshooting, repair, counseling, and the need for medical clearance.

The Present and Future Landscape

Presently, providing services in a nontraditional setting would be challenging. Self-testing and telehealth systems are certainly on the horizon but widely not available yet. In all likelihood, these systems will have greater visibility in the next 5 years. With automation and telehealth, it should be possible to have efficient, accessible, low–cost, and safe hearing health care services.

In addition, it should be remembered that our younger generations are growing increasingly technology-oriented. Can we take advantage of this familiarity with technology to improve their hearing health care? Specifically, is it possible to use YouTube, Facebook, texting, instant messaging, interactive video, web self-training sites, and blogs to provide services to these individuals with hearing loss? The future will yield exciting technology advances for audiologists. Consumers in the near future will likely use technology that we have not yet seen, invented, or even imagined.

About the Author

Mark Krumm is an associate professor in the School of Speech Pathology and Audiology at Kent State University in Kent, Ohio. He has been involved with telehealth applications for over a decade and has published a number of articles describing audiology telehealth use with pure-tone audiometry, otoacoustic emissions, immittance, video-otoscopy and the auditory brainstem response. He has also chaired the American Speech-Language-Hearing Association committee on telepractice and is presently the cochair of the American Academy of Audiology task force on telehealth. Contact him at


Davis, A., Smith, P., Ferguson, M., Stephens, D., & Gianopoulos, I. (2007). Acceptability, benefit and costs of early screening for hearing disability: A study of potential screening tests and models. Health Technology Assessment, 11, 1–294.

Margolis, R. H., Glasberg, B. R., Creeke, S., & Moore, B. C. J. (2010). AMTAS - Automated Method for Testing Auditory Sensitivity: Validation Studies. International Journal of Audiology, 49, 185–194.

National Institute on Deafness and Other Communication Disorders. (2009, August). NIDCD Working Group on Accessible and Affordable Hearing Health Care for Adults With Mild to Moderate Hearing Loss [Summary of meeting]. Retrieved from

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Smits, C., Merkus, P., & Houtgast, T. (2006). How we do it: The Dutch functional hearing screening tests by telephone and Internet. Clinical Otolaryngology, 31, 436–455.

Swanepoel, D., Koekemoer, D., & Clark, J. (2010). Intercontinental hearing assessment—a study in tele-audiology. Journal of Telemedicine and Telecare,16, 248–252.

Yao, J., Givens, G., & Wan, Y. (2009). A Web services–based distributed system with browser–client architecture to promote tele-audiology assessment. Telemedicine and e-Health, 15, 777–782.


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