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AJA
Clinical Focus
Innovation in the Context of Audiology
and in the Context of the Internet
Lynne E. Bernstein,
a
Jana Besser,
b
David W. Maidment,
c,d
and De Wet Swanepoel
e,f,g
Purpose: This article explores different meanings of
innovation within the context of audiology and the
Internet. Case studies areusedtoillustrateand
elaborate on the new types of innovation and their
levels of impact.
Method: The article defines innovation, providing case
studies illustrating a taxonomy of innovation types.
Results: Innovation ranges from minor changes in
technology implemented on existing platforms to radical
or disruptive changes that provide exceptional benefits
and transform markets. Innovations within the context of
audiology and the Internet can be found across that range.
The case studies presented demonstrate that innovations
in hearing care can span across a number of innovation
types and levels of impact. Considering the global need for
improved access and efficiency in hearing care, innovations
that demonstrate a sustainable impact on a large scale,
with the potential to rapidly upscale this impact, should be
prioritized.
Conclusions: It is unclear presently what types of innovations
are likely to have the most profound impacts on audiology
in the coming years. In the best case, they will lead to more
efficient, effective, and widespread availability of hearing
health on a global scale.
Agreement is widespread that audiology is changing
due to innovations afforded by the Internet and
smartphones. However, not all innovations have
the same value, cost, or implications. Several panel discus-
sions took place during the Third International Meeting on
Internet & Audiology, July 27–28, 2017. In the last panel
session, the authors of this article described their perspectives
on innovation and entrepreneurship in the context of audi-
ology and the Internet, which is the topic of the current
report. A panel session from the Second Meeting on
Internet & Audiology (September 24–25, 2015) was con-
cerned with impediments to the use of hearing health care
data. The authors stated that “today’s disjointed landscape
prevents the development and implementation of new solu-
tions of benefit to professionals, users, and hearing care
systems”(Laplante-Lévesque et al., 2016, p. 261). The in-
novation landscape today is no less disjointed. To impose
some structure on its complexity, this article outlines a tax-
onomy of types of innovation and illustrates them with
case studies in the context of audiology and the Internet.
The authors here express some concerns that, in the ab-
sence of a framework to discuss and evaluate innovation,
opportunities and resources may be squandered in develop-
ing products and services that are minor innovations,
whereas only radical or disruptive innovation can solve
pressing needs for hearing health care.
Worldwide, hearing loss is now recognized as a lead-
ing contributor to the global burden of diseases. It is the
fourth leading cause of years lived with disability (GBD
2015 Disease and Injury Incidence and Prevalence Collabo-
rators, 2016). Prevalence estimates for 2015 indicate that
1.33 billion people suffered from hearing loss, of which
473 million had disabling hearing loss (> 40 dB in the better
hearing ear; World Health Organization [WHO], n.d.).
More than 80% of persons with hearing loss reside in low- to
a
Department of Speech, Language, and Hearing Sciences, George
Washington University, Washington, DC
b
Department of Science and Technology, Sonova AG, Stäfa, Switzerland
c
National Institute for Health Research, Nottingham Biomedical
Research Centre, Nottingham, United Kingdom
d
Hearing Sciences Section, Division of Clinical Neuroscience, School of
Medicine, University of Nottingham, United Kingdom
e
Department of Speech-Language Pathology and Audiology,
University of Pretoria, Gauteng, South Africa
f
Ear Sciences Centre, School of Surgery, University of Western
Australia, Nedlands, Australia
g
Ear Science Institute Australia, Subiaco, Western Australia
Correspondence to Lynne E. Bernstein: lbernste@gwu.edu
Editor-in-Chief: Sumitrajit (Sumit) Dhar
Editor: Ariane Laplante-Lévesque
Received January 16, 2018
Revision received June 15, 2018
Accepted June 18, 2018
https://doi.org/10.1044/2018_AJA-IMIA3-18-0018
Publisher Note: This article is part of the Special Issue: Internet and
Audiology.
Disclosure: Lynne E. Bernstein is a principal of SeeHear LLC, a small business
with interest in technology for evaluating and ameliorating hearing loss. Jana Besser
is employed by Sonova AG, a provider of hearing solutions. De Wet Swanepoel’s
relationship with the hearX Group and hearZA includes equity, consulting, and
potential royalties. David W. Maidment has declared that no competing interests
existed at the time of publication.
American Journal of Audiology •Vol. 27 •376–384 •November 2018 •Copyright © 2018 American Speech-Language-Hearing Association376
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middle-income countries (LMICs) where the vast majority
are unable to access hearing health care services (Wilson,
Tucci, Merson, & O’Donoghue, 2017). Even in high-income
countries, the penetration of hearing health care services
and uptake of interventions remain low. The costs associ-
ated with untreated hearing loss include psychosocial fac-
tors such as impaired communication, depression, social
isolation, and cognitive decline (Wilson et al., 2017), with
real-world annual costs of hearing loss estimated to be $750
billion (WHO, 2017a). In light of what is now known about
the costs of hearing loss, the importance and necessity of in-
novation in the hearing care industry is clear and urgent.
A taxonomy of the impact of innovation and types
of innovations at multiple levels was created for the soft-
ware industry by Edison, Ali, and Torkar (2013). Although
we acknowledge that their taxonomy specifically focuses
on software technology, we posit that it can also be use-
fully applied to areas of audiologic innovation that are
coming to the forefront and will have a global impact on
audiology. In addition, having a framework to discuss and
evaluate these innovations is needed. Innovation in audio-
logic care and service delivery related to the Internet and
mobile technology can be expected in different parts of
the typical patient journey, including diagnostics, hearing
device acquisition, fitting and fine-tuning hearing aids,
counseling and training, and collection of data from patients,
such as satisfaction ratings, general feedback, or expecta-
tions about future products and services.
Edison et al.’s taxonomy of impacts of innovations
includes the following levels: (a) relatively minor incremen-
tal changes when they are based on existing platforms, where
“platforms”here include services or delivery systems;
(b) market breakthroughs when they are based again on
existing core technology or platforms but provide a sub-
stantially higher benefit at the same cost; (c) technological
breakthroughs when they are based on a substantially
different technology but do not provide a superior cus-
tomer benefit for the same cost; and (d) radical or disrup-
tive innovations when they introduce new features or an
exceptional benefit at a cost that transforms or creates
markets.
The second level of the Edison et al. (2013) taxonomy
concerns types of innovation. There are four types: (a) prod-
uct innovation is the creation and introduction of techno-
logically new or improved products that are significantly
different from existing products; (b) process innovation
changes the way products are created; (c) market innova-
tion includes modified marketing, product design, and open-
ing up new markets; and (d) organization innovation includes
new business or clinical practices and remuneration sys-
tems. Table 1 lists the four types of impacts and the four
types of innovation with the case studies below entered into
the cells of the table.
The forces driving current innovation are divergent.
Case Study 1 describes a new model of service delivery using
mobile technology and minimally trained laypersons for
the early stages of the patient journey (i.e., detection, diag-
nosis, referral, and triage). This model was developed out
of necessity, that is, the lack of audiologic infrastructure in
LMICs. In contrast, Case Study 2 describes how the Inter-
net can be used as a venue to deliver existing services that
are currently underused (e.g., speech perception training)
in a way that makes them more attractive to patients and
clinicians. Case Study 2 also describes how the Internet
and mobile technology can be used to collect real-time user
feedback. The innovation impact in Case Study 2 is in-
creased services through learning from (potential) users.
Case Study 3 describes how changes in legislation can drive
market innovation. Specifically, it addresses the recent U.S.
over-the-counter (OTC) legislation, after which certain
types of hearing devices for adults with mild-to-moderate
hearing loss will be available without the involvement of a
hearing care professional, thereby increasing accessibility
and affordability and transforming the current hearing aid
acquisition and fitting approach. The OTC model is closely
linked to recent advances in hearing device technology re-
garding connectivity to other devices or the Internet. Case
Study 4 describes how increased hearing device connectiv-
ity drives innovation in the audiologic care process toward
a more patient-initiated rehabilitation path. Case Study 5
describes a market breakthrough for hearing testing.
Case Studies
Case Study 1: Market Innovation
Through Necessity
Innovation impacts that range from market break-
throughs to radical or disruptive changes are appearing
in the ear and hearing health care markets. It is not surprising
that many of these new technology- and connectivity-driven
digital health market innovations are from small digital
health start-ups, often based in LMICs. The tremendous
demand for hearing health care services globally, especially
in LMICs, and the almost total dearth of available resources
in regions such as sub-Saharan Africa (Mulwafu, Ensink,
Kuper, & Fagan, 2017; WHO, 2017b) are driving market
innovations. Although only preliminary evidence is avail-
able for many of the new approaches (Swanepoel, 2017b;
Yousuf Hussein et al., 2016), a recurring focus is on decen-
tralization of access to ear and hearing care while making
services simple and efficient enough to be community based.
New service delivery models have been made possible
through rapidly evolving novel digital health solutions for
detection, diagnosis, referral, triage, and interventions
(Swanepoel, 2017b; Swanepoel, Myburgh, Howe, Mahomed,
& Eikelboom, 2014; Yousuf Hussein et al., 2016). In high-
income countries, the focus of these technologies and service
delivery models is accessibility and affordability, with a
strong drive to increase uptake and efficiencies in hearing
care services in existing systems. In this sense, innovation
in markets in high-income countries may be considered
less radical than that in LMICs.
For example, in South Africa, a model that is pres-
ently being tried uses minimally trained persons to facili-
tate primary hearing care services and connected solutions
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that can make appropriate referrals to available hearing
health providers based on location. Using low-cost smart-
phones connected to calibrated headphones allows the hear-
Screen and hearTest applications (hearX Group, Pretoria,
South Africa) to facilitate rapid hearing screening and follow-
up audiograms using minimally trained persons (Swanepoel,
2017b; Yousuf Hussein et al., 2016). Designed to simplify
and automate the test procedures, these mHealth tools also
incorporate rigorous, advanced-quality control measures
such as real-time noise monitoring, test operator, and pa-
tient quality indices, so that a decentralized, mobile, service
delivery model can be supported. Furthermore, linking these
smart hearing test devices to a cloud-based data manage-
ment system allows for location-based referrals via text
message, surveillance, specialist support, and advanced
reporting.
According to the Edison et al. (2013) taxonomy, the
innovations here cover product process and market innova-
tion types. The product innovation has its primary impact
as a technological breakthrough allowing for low-cost, au-
tomated, mobile audiometric testing by minimally trained
laypersons (see Table 1). The process innovation entails a
change in the way products are created by utilizing off-the-
shelf hardware with proprietary software to allow dedi-
cated medical applications. The market innovation impacts
across market and product breakthrough and disruptive
elements. The technology, including the point-of-care mo-
bile diagnostic and cloud data management, facilitates new
market exploitation with the technological breakthroughs
and allows a radical or disruptive impact for accessibility
of hearing health care using simple low-cost connected so-
lutions that minimally trained persons can operate, a radical
departure from audiologic practice carried out by individuals
with postgraduate education. The platform also offers a
smartphone-connected otoscope (hearScope) that makes cap-
turing an image of the tympanic membrane simple. This ap-
proach affords the possibility of an image-based diagnosis
using a proven artificial intelligence image-based analysis
approach (Myburgh, Jose, Swanepoel, & Laurent, 2018;
Myburgh, van Zijl, Swanepoel, Hellström, & Laurent, 2016).
These innovations enable novel service delivery models
that were impossible in LMICs and high-income countries
(Swanepoel & Clark, 2018). As these technologies enable
new service delivery models, they also may encounter
difficulties in gaining acceptance in more established
markets as is often observed with disruptive innovations.
For example, there may be reluctance to distribute service
provision among trained and minimally trained persons
in high-income countries that have long-established audio-
logic services carried out by individuals with higher degrees.
This type of solution utilizing point-of-care smartphone
diagnostics integrated with a cloud-based data management
facility is also scalable to other solutions. For example,
this smartphone and cloud platform supports the inte-
gration of other related and complementary services such
as vision screening, that is, the possibility to provide
community-based hearing and vision test, referral, and
data management services, again using minimally trained
persons (example project: https://www.youtube.com/watch?
v=SDWltCfbPrY).
Case Study 2: Innovation Through Learning
From Potential Customers
A common belief among researchers is that eventually
their work will benefit society. The researchers’work is
typically driven by the researchers’definition of the prob-
lem. This approach has been notoriously unsuccessful in
producing real products. The gap between federally funded
research in the United States and new commercialized tech-
nology is referred to as the “valley of death,”where new
technologies go to die. The U.S. Small Business Innovation
Research grants that are awarded by the U.S. National
Science Foundation and the National Institutes of Health
have too often failed to result in viable businesses, and con-
sequently, society fails to benefit from the technologies
and/or science that was supported. The National Science
Foundation diagnosed the problem of the valley of death as
the result of researchers and engineers building things that
nobody actually cares about. The NSF Innovation-Corps
Teams program (http://www.nsf.gov/news/special_reports/
i-corps/index.jsp) focuses on teaching researcher teams about
product, process, and market innovations. It focuses on a
product development process that is driven by discovering
who the customer is, what their needs are, and how the
product can be marketed profitably.
Table 1. Taxonomy of innovation impacts and types.
Case
study
Innovation types
Innovation impacts
Product Process Market Organization Incremental
Market
breakthroughs
Technological
breakthroughs
Radical
or disruptive
1XXX —— XXX
2XX —XX —X
3XXX X —— — X
4—X—X—— — X
5X—— — X——
Note. This taxonomy is adapted from Edison et al. (2013). The cells in the table list the case studies that illustrate the innovations. Em dashes
indicate data not applicable.
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Bernstein and colleagues (S. P. Eberhardt, G. Miller,
and E. T. Auer) from George Washington University set
out to determine whether there was a market for an inno-
vative Internet-based approach to speech perception train-
ing to support better audiovisual (AV) speech perception
in noise by individuals with hearing loss. The Internet is an
obvious venue for speech perception training, and a variety
of applications are already becoming available, but the im-
petus for training programs appears to have come from cli-
nicians and researchers exclusively. There is no evidence
that potential trainees have had an impact in determining
the design of the training programs, beyond participating
as test or clinical users.
The rationale for speech perception training from the
researchers’perspective seems straightforward. Even in the
absence of elevated auditory thresholds, many older adults
experience difficulties perceiving speech in noisy settings
(Humes et al., 2012; Pichora-Fuller, Schneider, & Daneman,
1995; Sommers, Tye-Murray, & Spehar, 2005; Tye-Murray
et al., 2008), and even with hearing aids, difficulties persist,
because hearing aids do not adequately compensate for
auditory distortions and poor signal-to-noise ratio (SNR;
Gordon-Salant & Fitzgibbons, 1999; Pichora-Fuller & Souza,
2003; Sheft, Shafiro, Lorenzi, McMullen, & Farrell, 2012).
One possibility is that auditory training approaches can be
developed that overcome difficulties that arise during con-
versational speech in noise. However, about a decade ago, a
meta-analysis (Sweetow & Palmer, 2005) of adult audio-
logic rehabilitation studies found only six studies that met
inclusion criteria for scientific methods and concluded that
there was “very little evidence for the effectiveness”of au-
ditory speech perception training. More recently, modest
results from auditory training have been reported (Anderson,
White-Schwoch, Choi, & Kraus, 2013; Chisolm & Arnold,
2012; Henshaw & Ferguson, 2013; Humes, Burk, Strauser,
& Kinney, 2009; Karawani, Bitan, Attias, & Banai, 2015).
Thus, although the Internet and home computer would
seem a perfect solution for delivering a training product,
there does not appear to be a breakthrough product yet
available.
Bernstein’s Innovation-Corps team questioned who
might care about such a product beyond researchers work-
ing on the problem. Initially, the team thought that a train-
ing system might be useful to and distributed through
audiology practices. Thirty-six individuals with degrees in
audiology from across the United States and in Europe
and Australia were interviewed.
1
Many of the interviews
were carried out using Internet videoconferencing applica-
tions. They covered a spectrum of activities from being
hearing aid providers, rehabilitation audiologists, clinic
directors, and researchers. They were asked about their
familiarity with a variety of software or Internet products
for training auditory speech perception and/or lipreading.
Their overall assessment was that these products might be
useful to some patients but had not yet delivered sufficient
levels of success to warrant enthusiasm. The audiologists
who identified as “rehabilitation audiologists”were gener-
ally more interested in Internet training geared toward
learning life skills to cope with hearing loss. Rehabilitation
audiologists were knowledgeable about the limitations of
available speech perception training programs for older
adults with hearing loss. The team concluded that a speech
perception training system would need to have shown a
significant benefit beyond what has been reported through
scientific testing before clinicians could be regarded as cus-
tomers or recommenders for the system.
The interviewers thought that lipreading training
could be attractive to older adults with hearing loss, be-
cause noisy situations frequently afford visual and auditory
speech information, and AV speech can functionally im-
prove SNR. However, the functional improvement varies
substantially across individuals. A significant proportion of
the individual variation may be attributable to visual speech
perception ability (Grant, Walden, & Seitz, 1998; Ross,
Saint-Amour, Leavitt, Javitt, & Foxe, 2007; Summerfield,
1991). This individual variation and its role in the benefit
obtained with AV speech have implications for ameliorat-
ing difficulties during face-to-face communication. Specifi-
cally, effective training on visual speech perception can
generalize to AV speech perception in noise. Furthermore,
given that most adults who have experienced healthy hearing
throughout most of their lives are poor lipreaders (Auer &
Bernstein, 2007; Bernstein, Demorest, & Tucker, 2000),
there is ample room for improvement. However, the ques-
tion was whether this potential solution matters to older
adults with hearing loss. Forty-seven adults with hearing
loss, the majority older, were interviewed about their hear-
ing health needs and experiences and their possible interest
in an Internet-based training system. Many of the inter-
views were carried out using Internet videoconferencing
applications. These interviews identified subgroups with
different experiences of hearing health and different needs
and desires. Training was not deemed attractive by those
with mild-to-moderate hearing loss and who were relatively
satisfied with their hearing aids. In contrast, training was
viewed as potentially attractive to those with more severe
hearing loss and with difficulty using hearing aids in noisy
social situations.
However, there were several significant caveats that
the team learned about within this latter group. First, in-
terest in training would be limited if the users could not
quickly discern benefits. That is, if their subjective impres-
sion was that they were not learning enough or quickly,
they would be likely to lose interest. Second, they did not
want to be bored, but they were also not generally interested
in gamified training. They were not interested in a training
experience that was not respectful of their interests or level
of maturity. Third, they expressed willingness to pay for
training if it were effective. They knew that their problems
were significant and would put money into effective solutions.
Fourth, their potential interest in training depended on how
1
These interviews were not carried out within the context of an
institutional informed consent protocol. Therefore, this case study is
not described as a research study.
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the topic was introduced during the interview. A common
pattern was to reject the idea of learning to lipread and yet
to embrace the idea that being able to use visual speech
information would be helpful, suggesting that education
about the benefits of AV speech perception and its reliance
on lipreading ability would be needed by some individuals
to motivate training.
Although most scientific research projects on training
use small amounts of pay to participants to use the train-
ing system and to acquire scientific data, a successful prod-
uct would have to involve an investment on the part of the
trainee. Even if training were free, the trainee would have
to decide to invest time and energy in the training. There-
fore, a training product would have to be radically more
effective and more engaging than any products to date. In-
terviews suggested that it would need to have a far different
“feel”than anything that has come out of the laboratory
or clinical research. For example, it may need to be wrapped
in a lifestyle product or social media context. The process
of developing such a product may come through the Lean
Startup model (Blank & Dorf, 2012), which is designed to
quickly develop minimal viable products to test product
attractiveness. The minimal viable product process is radi-
cally different from the laboratory development process
that invests large amounts of resources to obtain scientific
evidence in advance of investigating customers’preferences.
A commercially viable product may need to demonstrate
customer engagement before or in tandem with scientific
proof. Case Study 2 is listed in Table 1 as a radical product
in the sense that a lipreading training system would attempt
to solve the speech-in-noise perception problem through
improved AV speech processing and would also require
long-term engagement with training. The approach to de-
velopment is also potentially radically different from devel-
opment within the laboratory or clinical impetus.
Rather than interviewing people to learn about their
experiences, it is also possible to use mobile technology
and smartphone connectivity to collect data from them in
real time. Timmer, Hickson, and Launer (2017) have recently
shown how an ecological momentary assessment can be
used to acquire subjective ratings of listening situations
from hearing aid users, while they are in specific situations.
Hearing aid users filled in very short surveys on a smart-
phone about several aspects of the listening situation they
were experiencing. The surveys could be initiated by the
user, could be triggered at random times during the day,
or could be triggered based on criteria of the acoustic envi-
ronment, monitored by the hearing aid. The hearing aids
tracked data such as estimated overall sound level, SNR,
and percentage of speech, noise, and music in the environ-
ment. Ultimately, the subjective user ratings and technical
measurements from hearing aids could be linked to improve
hearing aid signal processing in general or situationally.
This example is listed in Table 1 as an incremental market
innovation with regard to hearing aids, as they use existing
technology. However, it is also possible to imagine more
radical uses of an ecological momentary assessment that
might, for example, be coupled with artificial intelligence
to carry out listening or communication tasks that are too
difficult for a hearing aid user.
Case Study 3: Innovation in Device Accessibility
and Affordability Through Legislation
and OTC Products
OTC hearing aids are perceived as a disruptive inno-
vation in the field of audiology as well as an overdue re-
sponse to unmet needs on the part of consumer advocates.
In Table 1, Case Study 3 is listed as having a radical im-
pact as a product and a process.
The U.S. Over-the-Counter Hearing Aid Act of 2017
was signed into law requiring that OTC hearing aids are
for individuals with mild-to-moderate hearing loss. It re-
quires that the hearing aids meet the same safety, consumer
labeling, and manufacturing protections that all other U.S.
medical devices must meet. According to The National
Academies of Sciences, Engineering, and Medicine, “This
approach would enable consumers and patients to take
more control over their own health conditions. The com-
mittee also emphasizes the need for greater transparency
through the unbundling of prices for hearing health care
services and related technologies and raising awareness of
patients’rights of access to their hearing health care infor-
mation and records”(The National Academies of Sciences,
Engineering, and Medicine, 2016).
The OTC movement was primarily triggered by is-
sues concerning hearing aid access and affordability (The
National Academies of Sciences, Engineering, and Medicine,
2016). However, the impact of disruption that is arising
from OTC hearing aids is expected not only at a local level
but also globally. Issues surrounding accessibility and afford-
ability are evident not only in consumer-driven markets
but also where the provision of hearing aids is free; hearing
aid uptake and use are relatively low, irrespective of the
health care system (Barker, Mackenzie, Elliott, Jones, &
de Lusignan, 2016). Untreated hearing loss in older adults
has become an even greater concern given its association
with other health conditions, including anxiety and depres-
sion (Ciorba, Bianchini, Pelucchi, & Pastore, 2012), and an
increased risk of developing dementia (Lin et al., 2011).
Thus, the ultimate goal of OTC hearing aid provision is
to substantially increase market penetration and thereby
dramatically reduce the negative individual and societal con-
sequences of untreated hearing loss. For these reasons,
it is perhaps unsurprising that alternative service delivery
models are being considered that aim to improve accessi-
bility of hearing services for people living with hearing
loss who do not (or cannot) access hearing aids.
A recent scientific study (Humes et al., 2017) exam-
ined some possible effects of the OTC market on patients.
Its results suggest that, even with comparable benefits in
speech understanding, patients who do not have any con-
tact with an audiologist during the rehabilitation process
will be less satisfied with their hearing aids, exhibit poorer
hearing aid handling skills, and experience higher perceived
aided hearing handicap. However, the availability of OTC
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hearing aids is likely to result in changes in patient behav-
ior that cannot be reliably predicted at this time. For example,
online reviews of hearing aid buying and using experiences
may result in a more accurate understanding of the advan-
tages and disadvantages of particular OTC hearing aids as
well as other types of practical advice. Clearly, these are
“early times”in this market.
Case Study 4: Patient-Driven Rehabilitation
This case study is listed as a disruptive innovation
regarding process and organization, because connectivity
of hearing devices and the resulting implications for audio-
logic care have the power to transform the current market
by changing business practices. Heretofore, audiologic ser-
vices and products have been provided almost exclusively
by clinicians with specialized knowledge and equipment in
the setting of an audiology clinic. The patient visits the
clinic for all of his or her hearing health concerns (e.g., as-
sessments, counseling, hearing aid fittings and fine-tuning,
hearing aid maintenance and repair, and purchasing of
batteries and accessories). The patient-initiated consulta-
tion sets the clinician’s procedures into motion. The emer-
gence of new distribution channels for standard hearing
devices, such as online purchases, and the introduction
of OTC products imply that patients can exert more control
over and have more responsibility for their own hearing
rehabilitation.
In a patient-driven model of audiologic care, both
the patient and the clinician take responsibility and actions
for successful hearing rehabilitation, but the extent of clini-
cian involvement is determined by the patient to a greater
extent than in the traditional model. The OTC buyer will
self-test hearing, select/fit a hearing device, manage device
maintenance and repair, and develop everyday strategies
for functioning with a hearing loss. These options may be
facilitated by developments in mobile technology and hear-
ing device connectivity that enable adjustment of hearing
aid settings by the patient, using nonprofessional equipment.
Additional benefits could be created if clinicians were
available for professional paid services at each stage of the
rehabilitation process. For example, the patient could
choose to get an additional audiologist checkup for ear ca-
nal blockage due to cerumen before self-fitting his or her
hearing aids. The audiologist could be consulted to solve
issues during fitting, such as making real-ear measurements
or fine-tuning, helping with hearing device repairs, and so
forth. Patients thus become the initiators, and clinicians act
as resources for problems that cannot be managed alone.
Because of a greater connectivity in hearing devices through
Bluetooth and Internet and because of the integration of
remote-fitting options available to the clinician, parts of
the hearing rehabilitation collaboration between patient
and clinician can be performed while the patient and the
audiologist are in different geographical locations. Such an
approach increases the accessibility of audiologic services,
especially for patients living in rural areas or parts of the
world where audiologic clinics are scarce. It also saves time
for the patient and increases access for people who are not
mobile enough to visit a clinic. Remote hearing care ses-
sions can be used to test hearing aid fittings real time in
the patients’living environment and together with their
family, increasing patient-centeredness.
Audiologists may also be coaches and counselors on
questions of hearing health (Grenness, Hickson, Laplante-
Lévesque, Meyer, & Davidson, 2015; Meibos et al., 2017).
For example, psychosocial counseling was found to posi-
tively influence the patient’s hearing rehabilitation decisions
and increase the success of hearing care (Ekberg, Grenness,
& Hickson, 2014). Counseling can benefit communication
strategies; reduce anxiety, hearing handicap, and disability;
and reduce restrictions on activity and participation (Aazh
& Moore, 2017).
In a study by Maidment and Ferguson (2017), the
views of 20 adults living with mild-to-moderate hearing
loss were explored concerning usability, delivery, accessibil-
ity, and acceptability of and adherence to a broad range
of smartphone-connected listening devices. Such devices re-
quire limited or no audiologic input because they can be
fitted and/or adjusted by the users themselves via a smart-
phone. Existing hearing aid users trialed one of the follow-
ing devices in their everyday lives for a period of 2 weeks:
smartphone-connected hearing aids, personal sound ampli-
fication product, or smartphone hearing aid–type applica-
tion used with wired or wireless earphones. After 2 weeks
of use, semistructured interviews were completed. Preliminary
analysis suggests that users want to personalize and ad-
just their own listening devices using a smartphone to im-
prove their ability to communicate in any situation. This
subsequently provides the user with a greater sense of
control, resulting in less frustration, greater participation,
and more device use. This study will be used to inform the
design of further high-quality evidence-based assessment of
the clinical effectiveness and cost-effectiveness of alternative
audiologic service delivery models that innovations in
smartphone technologies enable (see Maidment & Ferguson,
2017).
Case Study 5: Innovation Through Entrepreneurship
When considering innovation through entrepreneur-
ship, it may be useful to make a distinction between tra-
ditional conceptions of entrepreneurship that are concerned
with generating personal/shareholder wealth and those
that focus on the creation of products, services, and/or or-
ganizations to improve social outcomes for a specific
stakeholder group (i.e., social entrepreneurship; Phillips,
Lee, Ghobadian, O’Regan, & James, 2015). Philips et al.
posit that social entrepreneurship and innovation share
common overlaps, whereby social entrepreneurs exploit
(or harness) innovative activities and/or services to ad-
dress unmet social needs or promote social developments.
As such, social innovation is not simply undertaken by
individual entrepreneurs working in isolation but involves
a wide range of individuals, organizations, and/or institutions
Bernstein et al.: Innovation in Audiology and the Internet 381
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working collectively to bring about social change (Phillips
et al., 2015).
In the context of audiology and the Internet, one such
example of social entrepreneurship is the development and
launch of a consumer smartphone application as a national
hearing test (Potgieter, Swanepoel, Myburgh, Hopper, &
Smits, 2016; Potgieter, Swanepoel, Myburgh, & Smits, 2018).
On World Hearing Day 2016, the hearZA smartphone ap-
plication was launched as South Africa’s national hearing
test, facilitating a free hearing test to every South African
from their smartphone. The test, which uses a digits-in-noise
test paradigm determining speech perception ability in
background noise, provides a result in 2 min. The hearZA
application is employed as (a) a strategic public awareness
tool for hearing health, (b) an accurate screening tool for
hearing loss, (c) a personalized hearing health tracker,
(d) an in-app decision support tool encouraging action on
hearing loss, and (e) a referral network to link people to
their closest hearing health providers based on geolocation
in partnership with national audiologic societies (Swanepoel,
2017a).
This social entrepreneurship endeavor is a product
innovation with its primary impact as a market breakthrough
offering extensive free hearing health services to the public
(see Table 1). As a social innovation, it was developed and
validated at the University of Pretoria and made available
commercially by the hearX group (Pretoria, South Africa;
Potgieter et al., 2016, 2018). To ensure that the national
hearing test app can be offered free of charge, strategic
partnerships with various sponsors, of which the largest
mobile operator in South Africa (Vodacom) is the primary
sponsor, needed to be developed alongside the support of
the national audiology associations (Swanepoel, 2017a).
The success of this social entrepreneurship project has seen
almost 50,000 persons tested and thousands referred to lo-
cal hearing health specialists. South African celebrities serve
as hearing health ambassadors for the application (see https://
www.youtube.com/watch?time_continue=2&v=ULBpdo_
k-mg) and support the national marketing and advocacy
campaigns to ensure the ongoing success of this initiative.
This technology also covers a type of organizational
innovation with impact in the market breakthrough segment
(see Table 1). The referral system linking patients directly
to audiologists according to test and clinic geolocation pro-
vides new verified leads to patients requiring services and
amplification. This generates a new business opportunity
with the possibility of also placing hearing test kiosks in
community-based locations such as pharmacies, general
practitioner offices, and optometry practices.
General Discussion
Innovation has accelerated with the growth and ad-
vancements in the Internet and mobile devices, and audiology
is changing as a result. However, adoption of innovation,
especially in health care, is often delayed due to market re-
sistance from health providers. Part of the challenge is to
appropriately classify and review innovations within a larger
framework. As argued at the outset of this article, the in-
novation landscape today is somewhat disjointed, not least
because the forces driving innovation tend be quite diver-
gent. In the present article, we have attempted to address
this. Namely, the taxonomy provided by Edison et al.
(2013) and illustrated by the case studies considered above
allows for a more holistic view of innovation types and
their respective impact.
An interesting outcome of using the Edison et al.
taxonomy is the observation that many of the innovations
in the case studies are expected to deliver more than one
type of impact. In addition, many of the innovations were
considered to be radical, inasmuch as they are expected to
alter the practice of audiology while increasing the range
of products and services that may hopefully become uni-
versally available at affordable prices.
Case Study 1 describes an innovative model of service
delivery using mobile technology and minimally trained
laypersons for the stages of detection, diagnosis, referral,
and triage of hearing loss. To do this requires technical
breakthroughs and radical changes in the process and mar-
keting of audiologic services. Such developments were
driven by necessity, that is, the dearth of audiologic infra-
structure in LMICs. Case Study 2 describes a customer dis-
covery process that is typically not carried out in the context
of research studies concerning speech perception training,
including lipreading training. It revealed that training
products, no matter how effective they might be in the lab-
oratory, would have to also incorporate approaches that
would make them attractive enough to keep users engaged
over extended periods and even pay for use of the training
platform. It is not presently clear how this might be ac-
complished. Case Study 2 also pointed out that an ecologi-
cal momentary assessment could be used to understand
patient needs. Case Study 3 outlines market innovation
through legislation and consumer advocacy. Although leg-
islation and advocacy are not themselves radical innova-
tions, the recent passage of the OTC hearing aid legislation
in the United States is expected to have innovation im-
pacts that are felt to be radical by both audiologists and
patients. Case Study 4 described how the Internet and the
consumer market for hearing devices could redefine how
professional audiologist services are used by patients, an-
other potentially radical innovation at the level of markets.
Case Study 5 introduced the concept of social entrepre-
neurship used to achieve market breakthroughs. A free
national hearing test with direct links to providers has the
potential to be an almost universal funnel connecting indi-
viduals with hearing health problems to solutions.
Conclusion
Audiology as a profession has always been closely
tied to technological innovations. With the advent of the
Internet and rapid growth in technology connected to the
Internet, health care is seeing an unprecedented rise in in-
novation, and hearing health care is no different. The inno-
vations discussed in this article point toward development
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of hearing health care that will grant both higher accessi-
bility and greater affordability of hearing devices and audi-
ologic services. These services address all of the stages of
the patient journey, from screening to device fitting, coach-
ing on hearing device usage, and auditory and speech per-
ception training. Thus, the field of audiology is evolving to
serve more people, earlier, with higher-quality services than
ever before. This is a great opportunity for our profession,
and it is our responsibility to make sure that the potential
will be realized. We need to cultivate a culture that values
innovation and that quickly incorporates evidence-based
innovations to reach more patients and improve patient
outcomes.
Acknowledgments
Lynne Bernstein received support from the U.S. National
Science Foundation (1738164). David Maidment is funded by the
National Institute for Health Research Nottingham Biomedical
Research Center.
Portions of this article were presented at the 3rd International
Internet & Audiology Meeting, Louisville, KY, July 2017, and funded
by NIDCD Grant 1R13DC016547 and the Oticon Foundation.
The views expressed here are those of the authors and not
necessarily those of the U.K. National Health Service, the National
Institute for Health Research, or the Department of Health and
Social Care.
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