The Technological Evolution of Today’s Hearing Aids

Learning Outcomes

After this course learners will be able to:

• Describe to colleagues and business partners how hearing aids are becoming smarter and more capable.
• Discuss new features and capabilities available in today's hearing aids.
• Describe what type of hearing aid functionality to expect in the near and long term.

Introduction

Thank you for joining me as I walk through the different technological changes the hearing aid is undergoing. I work with Oaktree Products and also launched a blog, Future Ear. I gave a presentation previously, Connectivity and Future Hearing Aid Applications that allowed me to share my thoughts and became the foundation of today's discussion. Oaktree Products was started back in 1992 by my parents, Bob and Margy Kemp. We are a family-oriented company and have grown to be one of the biggest suppliers of clinical supplies to the audiology industry. One of the ways we have found success is by differentiating ourselves by serving the industry through educational material, presentations, and webinars like this. I hope I can serve as a resource with this presentation. I hope to aggregate and distill down all of the information that is relevant to the hearing care professional and industry as it relates to technological innovation. I know that you are all very busy and have to stay abreast of what is happening in the industry, let alone staying updated with technology and the rapid pace of change. My goal is to aggregate that information for you.

Understanding Your Value

While I will discuss devices and their various functions, I want to make it clear that the hearing care professional is crucial to the whole equation. Just because these devices are becoming more technologically relevant, does not mean the professional becomes obsolete. Christopher Scheitzer said it best, "Hearing care professionals lamenting the dwindling average selling price for their products must recognize the increasing rarity, and hence high value, of trust in the provision of knowledgeable assistance." The idea of being this provision of knowledgeable assistance is vital. We know the market is abundant with options. Think about the new big-box retailers that are selling OTC devices and different online options. There is a multitude of choices available to patients today. The actual provision of knowledgeable assistance is more valuable than ever. Patients will look to experts for guidance. As the clinician, you are in a position to be that provision of knowledgeable assistance.

When we think about the value proposition, there are three different aspects to it. There are marketplace offerings, which you can not control. These are things that the hearing aid manufacturers are bringing to market (i.e., new technology, devices). Then you have the consumer needs and expectations. This is everything that the consumer is needing and looking for. The one-piece that you can control is your offering. This goes back to this idea of being a provision of knowledgeable assistance. What I want to highlight is how we can take these technological changes in the marketplace and use them as ammunition in that process. You can use them when the patient is in your practice or in marketing materials to incentivize them to come to see you.

Figure 1. Your Value Proposition.

Potential and Penetration Rate

If we were to assess why the hearing aid penetration rate has historically sat at around 22 to 25%, most people would attribute two of the main factors to be price and stigma. I will not discuss price today as that is a discussion in and of itself. What I will focus on today is stigma.

Discussion Overview

During this course, I will offer a blueprint of the combined effort between the professionals and macro trends that are emerging. I believe that these two aspects will change the negative stigma that surrounds hearing aids through normalization and popularization. We will discuss the booming hearables market and how the increase of functionality lends itself to the "cool factor." We will also cover the aural attention economy and VoiceFirst. Then move on to discuss the transformation these devices are undergoing which are transforming them into life-saving devices with biometrics, preventative health, and the longevity economy.

Normalization and Popularization

Defining Hearables

If we consider a wearable as a body-worn computer (e.g., Fitbit, Apple Watch), then a hearable is a body-worn computer that you wear in your ear. The International Data Center (IDC), a research body that publishes consumer technology research, defines it as having at least one of the following features:

• Track health/fitness (e.g., Samsung Gear IconX)
• Modify audio, and not just noise reduction (e.g., Nuheara IQbuds)
• Provide language translation on the device (e.g., Waverly Labs)
• Enable smart assistants at the touch of a button or through hotword detection even if the assistant is running on another device such as a smartphone (e.g., Apple's AirPods and Google's Pixel Buds)

I think it is essential to distinguish between hearing aids and hearables. Keep in my mind that hearing aids are very much hearables, as they are an ear-worn computer. 

Innovation Happening Inside the Devices

When we think about the broader perspective of hearing aids fitting into this bigger ecosystem of devices, some exciting innovations are happening inside the devices.

Sonova SWORD Chip. In our industry, we have companies like Sonova, who developed the SWORD chip. The SWORD chip is a computer chip inside of the Phonak Marvel and Unitron Discover. It is the type of chip that can support five different Bluetooth protocols. This chip enables universal connectivity. It allows the Roger mic direct capabilities so that you do not need to wear an intermediary device. It can stream directly into your hearing aids. 

Digital Signal Processing (DSP). Digital signal processing chips are relevant both inside and outside of our industry. There has been a ton of innovation around these. You have companies like Qualcomm that have the QC5100 series, which is the most sophisticated hearable architecture. It allows for lower power consumption. You can integrate active noise cancellation into a single chip. The reason that's so important to point out is that in a device that's as small as an in-the-ear device, there are different battery constraints. That's always been the limiting factor when it comes to in-the-ear devices. That's where a lot of the hearing aid pioneering has focused on. What we're seeing coming from the consumer space is innovation around these DSP chips and enabling different ways in which we can preserve power and also create more robust functionality through miniaturization.

 Apple's H1 Chip. One of the best examples of this is Apple's H1 chip. This chip was introduced with the AirPods version before the AirPods Pro that was released recently. This is a hearable-specific chip from the largest consumer technology company out there, Apple. It creates the ability for hearable-specific functionality, such as the Hey Siri activation, that you can use with your voice.

The Bluetooth Shift

Bluetooth is another one of these fundamental and foundational innovations that have occurred. Within our industry, ReSound introduced the first Made for iPhone hearing aid, the LiNX. When Bluetooth was introduced, it was a novelty. Today, Bluetooth capability and compatibility are more or less a standard feature. All five hearing aid manufacturers now offer at least one. Most offer several different MFi hearing aids on the market.

Looking at the current day, Google released its Android 10 operating system, which now includes the Android Streaming for Hearing Aids low-power Bluetooth protocol. ASHA is the acronym that represents Google's "made for Android" hearing aid Bluetooth protocol. Google and the Android's open ecosystem (i.e., Samsung, HTC, Sony) over time will adopt that Android 10 operating system. I think this is interesting because just in this last HIA report that was issued of the hearing aids statistics from Q3 2019, 94% of hearing aids sold have wireless capabilities. We are on this trajectory right now, where we're getting closer and closer to the point where universal connectivity from any hearing aid to any smartphone is on the horizon.

Outside of our industry, we look at the more macro consumer industry. There's been a massive shift to Bluetooth around the same time that the Made for iPhone hearing aids started to come about. In 2016, Bluetooth headphone sales surpassed non-Bluetooth headphone sales for the first time. A few months after, Apple removed the headphone jack in the iPhone 7. Since then, this has just dramatically increased the rate at which we're using wireless Bluetooth headphones now.

The AirPods Effect. When we're thinking about this in the context of normalization, the biggest culprits behind that is AirPods. We look at how Apple consumers talk about their AirPods. There is a 98% consumer satisfaction rate with AirPods. The people that have begun to use these devices are most likely loyal consumers. It has created a new behavior shift. What we're seeing is the AirPods Effect, as I call it. Figure 2 shows a report from IDC that listed the top five hearables companies. The numbers are eye-popping, particularly the year-over-year growth on the far right side. You can start to see that this is a booming market. The total market is up 250%. Some of these numbers are just enormous, considering that it is one quarter alone. Apple, for example, sold 15.9 million devices in a quarter alone, 60 million units sold on an annual basis. In the last quarter, 31.8 million devices sold in this category. Again, this idea that we're undergoing a behavior shift within our population, where it's a new norm to wear these truly wireless devices. There were roughly four million hearing aids sold in all of 2019. In a short period, we're going to see the wireless earbud market eclipse the hearing aid market. That's a good thing because what it ultimately means is more incentive is being created to develop new applications and functionality in our industry. 

Figure 2. The AirPods Effect.

The Hearables Arena

We are at a point where all of the major tech giants are entering into this hearable's arena. They have seen the blueprint that Apple has established, and there is a vast market demand for these devices. Here are some of the competitors in this space.

Samsung. This year, Samsung, the biggest smartphone manufacturer out there in terms of unit devices sold, introduced the Samsung Galaxy Buds. In the period that these have been in the market, they've grown to capture about 10% of the market. This is because the Samsung Galaxy Buds were included with the purchase of the Samsung Galaxy S10.

Amazon. The Echo Buds have active noise cancellation. They have the pass-through audio that some might be familiar with products like Nuheara. We're now starting to see consumer products that have this feature. These are going to retail for $129. You can also tap to access Alexa with these devices.

Microsoft. Microsoft even came out with a hearable, the Microsoft Surface Buds. These are going to focus on enterprise applications and different voice assistant capabilities.

Google. The Pixel Buds debuted not long after the first version of AirPods was released. The Google Pixel Buds 2.0 will be released in the Spring of 2020. The big emphasis is on the voice assistant. There are various voice assistants, and these companies are adamant about getting this technology to our ears.

Apple. AirPods Pro became available and was met with positive reviews. They have active noise cancellation. They have Force Sensor on the stem of the device that you can squeeze, and it will toggle between active noise cancellation and pass-through audio. They are sweat- and water-resistant and have that H1 chip that I mentioned earlier.

We have some of the biggest companies in the world with the deepest pockets entering into a space that we are adjacent to. I think that's going to help normalize and popularize this idea that people are going to be wearing devices in and around their ears. Not only are they going to be wearing them in and around their ears, but they are also going to be wearing them for extended periods. We are moving toward a time where people are less self-conscious about wearing things in the ears because they can do so many different things with that technology. Hearing aids will become something that people do not think of when they think of the negative stigma that they typically associate it with today. It will just be another in-the-ear device that people are wearing.

The Hearables Explosion

I want to highlight the hearables explosion. Nick Hunn, who coined the term hearable, puts out a lot of different projections. He is projecting the market for hearables to grow to nearly 250 million devices by 2021. What is important to point out is the Bluetooth hearing aid takeover. In time, the Bluetooth technology becomes standardized. Bluetooth connectivity, when it first debuted, was a novelty. Now it's becoming a standard feature. We're going to see that these types of devices as a significant opportunity moving forward.

Figure 3. The Hearables Explosion. 

Reducing Stigma

I asked a friend of mine who started wearing hearing aids not long ago about his experience. He mentioned, "aside from mitigating my hearing loss, the hearable features of modern hearing aids are also a plus. I travel for work and either make calls or participate in internet meetings often enough that being able to connect them to my phone, tablet, or computer was important. For that reason, I chose a model with universal Bluetooth connectivity." These types of features and aspects are at the core of a patient's buying decisions. The hearing aid has always been designed to change lives by helping patients hear better, but the connectivity and these new features are equally important.

Increasing Functionality & "Cool" Factor

Let's talk a little bit now about how this will ultimately increase the functionality of the devices, and ultimately the cool factor. If we consider the mobile computing era, we think about all the major app success stories. By and large, these app success stories are referred to as the attention economy. The attention economy is essentially the notion that companies like Facebook, Twitter, Instagram, Snapchat, YouTube, and Netflix, whether it be through a subscription or an ad model, are exchanging their goods for your attention. You are giving your attention through one method or another. It is incredibly profitable for these different companies and has spurred these giant, billion-dollar companies to become the size they are because they are profiting from our attention. What is interesting is that we're starting to see this shift in a way toward our ears.

The Aural Attention Economy

Daniel Ek, who is the Spotify CEO, wrote a blog post right after Spotify acquired two companies. The first company was Gimlet Media, which make several different podcasts. The second company they acquired was Anchor, which is a podcast hosting platform. He says this: "To understand, take the current value of the video industry. Consumers spend roughly the same amount of time on video as they do on audio. Video is about a trillion-dollar market. And the music and radio industry is worth around a hundred billion dollars. I always come back to the same question: Are our eyes worth ten times more than our ears? I firmly believe this is not the case. For example, people still spend over two hours a day listening to the radio — and we want to bring that radio listening to Spotify, where we can deepen engagement and create value in new ways. With the world focused on trying to reduce screen time, it opens up a massive audio opportunity." We are becoming this new aural attention economy. Rather than giving your attention through your eyeballs or your phone, you're starting to give your attention through your ears or earbuds. We're starting to see things like the podcast economy begin to boom.

Podcasts. More than 50% of adults 12 and older have listened to a podcast at least once. About 22% listen to them weekly. For the folks that do listen to podcasts, the average weekly podcast consumption is three hours and 37 minutes. On average, Americans listen to seven episodes a week. Those that are listening to podcasts are listening to about seven episodes. This is a brand new medium. Consider when radio, television or film emerged, there were many phases of evolution of each medium.

Passive content consumption.  I recently asked a friend if his podcast consumption increased since wearing Bluetooth hearing aids. He told me that he would listen to podcasts throughout the day - all day. I do not think that he's an anomaly. We are referring to passive content consumption, the ability to continually consume information on your own time while you're on the go. Before, everything was active content consumption-oriented. For example, if you're watching a video, you tend to be sitting or standing and giving it your undivided attention. This is the same with reading. When you're listening to something, you can multitask. Now, with the emergence of the podcasting and the aural attention economy and audiobooks, you can position the hearing aid as a content consumption device as well.

Practical Applications

I'm not an audiologist, so I do not know how feasible this would be. I envision during a hearing evaluation or fitting that you would discuss or offer information about what a podcast or an audiobook is. A lot of these audiobook subscription services, like Audible, provide a free month for free. Perhaps your patient's eyesight has depreciated to the point where they were a voracious reader in the past, and now they are not reading as much as they used to. Then you introduce them to an audiobook because nobody has before. The fact that they can listen to an audiobook through their hearing aids may be a significant point for this patient. This creates a new aspect of hearing aids. When you add these incremental pieces of value, it might be something that people find value in and serves as a great referral source for you.

Voice First

Brian Roemmele coined VoiceFirst. He has been at the forefront of this whole notion that we're moving toward a point where voice assistants and voice technology will be our default way in which we interact with computers. It's not to say that we will be voice only, screens aren't going away. But over time, he believes that we're going to rely heavily on communicating through our technology with our voices.

This is rooted in the fact that every ten years or so, our user interfaces with technology tend to change. If we go back to the '60s, it was the punch card. Then it was the command line. In the '90s, when people started to bring PCs into their homes, the graphical user interface began to emerge with images and monitors. Then in the late '90s, you had the introduction of the internet and hypertext. In 2007, Steve Jobs famously ushered in the mobile era with the introduction of the iPhone. In 2017, we were starting to see different devices that house voice assistants: smart speakers, smart displays, Amazon's Alexa, Google Assistant, or Apple's Siri. When we look at this market, we look at the fact that the global smart speaker market today has sold about 170 million smart speakers. Loup Ventures, in conjunction with Voicebot, is projecting that by about 2025, just shy of 300 million smart speakers will be sold on an annual basis.

Smart speaker ownership by age group. What's interesting here is that older adults are using this technology as well. About 34 million older adults age 60 and older are using a smart speaker, and 46.6% are using their smart speaker daily. When we think about it, we need to realize that voice assistants are making their way to these earbuds. The five companies (e.g., Microsoft, Samsung, Google, Apple, and Amazon) realized that computing is moving to more ambient-type settings or voice assistant-oriented settings. 

Essentially, what we're thinking about here is how to navigate from point A to point B. If we look at the different eras in which we've used user interfaces, before the internet, how you would navigate yourself would be through a map or old fashioned directions. Then the internet came about, which allowed you to print off directions from websites like MapQuest. Today, you can pull up your phone and use Google Maps. You can start to imagine that as this becomes useful and integrated into our in-the-ear devices, what we're started to refer the hearing aid to then is sort of like a computer. In every sense of the word, in every way that we use a smartphone today, our hearing aids are going to function in a very similar capacity.

Rapid adoption of technology for adults 65+. There tends to be this notion that older adults have no affinity or proclivity to technology. The fact is they do adopt the technology. They tend to do so at a little bit of a later rate as everybody else. Smartphone adoption has nearly quadrupled in the last five years, and this number also includes users in this age range. 

Integrating Voice Assistants into Hearing Aids

Over time, these in-the-ear devices will be conduits to the voice assistant. The voice assistant will replace what we rely on our phones for. When we think about the way that we use our phones now, much of it is taskings. Trying to get from point A to point B or scheduling a ride from here to there. The practical application of this is to begin introducing this technology to your patients. This is a conducive user interface for older patients. Perhaps their dexterity might be compromised. Or their eyesight may have depreciated over time. When we think about a user interface that's seamless and frictionless, that's just using your voice; I think it caters to our patient demographic nicely.

Voice Assistants + Hearables 

Mobile accessory kits are enabling this third-party integration into things like hearing aids. We also see voice assistant providers, like Apple, Google, and Amazon, releasing devices of their own. This will create an incentive for the developer communities to develop applications. Much like they created applications for our phones and increased the value of the phone over time through the app economy. We are going to see similar types of things as economies, and in-app functionality economy starts to form in-the-ear devices.

The Longevity Economy

This is supposed to represent the baby boomer generation. They have different expectations. These people are able-bodied, and they are going to control a lot of aspects of the economy. In the United States, approximately 10,000 Baby Boomers cross the age of 65 each day. 

Silver tsunami. Baby boomers are set to control about 50% of the total wealth in the US. It's a group that has different expectations as to how they want to age. When we think about hearing loss, age tends to be one of the leading factors with hearing loss. We can imagine that these baby boomers are going to be in the market for a hearing aid. They do not want a hearing aid from their parent's generation. We all know, in our industry, that's not the case anymore. It's our job to help educate the broader population that these devices can do so much more.

Biometric Sensor Integration in Hearables

I believe one of the most significant aspects that will be of interest and will be appealing to the longevity economy and baby boomers are biometric sensors. We are starting to see biometric sensors integrated into hearables.

Accelerometers & Gyroscopes. You have the inertial sensors like accelerometers and gyroscopes starting to make their way into products like the Livio AI from Starkey. These enable fitness tracking so that you can get the number of steps that you've walked each day. You can see the intensity of those steps. It also enables things like fall detection.

PPG sensors. We also see things like PPG sensors making their debut. With the Livio AI, I believe there's now a heart rate sensor included. A photoplasmatic sensor, that's an optical sensor, it uses lasers to capture your heart rate and heart rate variability. Just very recently, these PPG sensors are now capable of capturing your blood pressure. We see how these devices, hearing aids, and consumer hearables have become data collection points. They are going to tools that allow you to create longitudinal data sets on an individual basis. This is a massive innovation, and I think one of the biggest things to happen in a long time in the healthcare space. Think about how you can start to take that data and make sense of it over time. We can see dips and spikes in things like your blood pressure. We can see what your fitness levels have been like for the year. We know that there are a lot of comorbidities involved with hearing loss. Some of those comorbidities can be managed through some of the different biometric monitoring that's going on here.

EKG sensors. We have now seen these introduced into things like the Apple Watch, which can detect heart rate and heart irregularities like atrial fibrillation. It's not in in-the-ear devices yet, but it's trending in that direction. This sensor was not included in previous generations of the Apple Watch. It is also called an electrocardiogram (ECG).

Why The Ear?

One of the questions that I've heard before is, why is the ear better for recording biometrics than the wrist? There are a couple of different reasons. First of all, the unique physiology, it's mostly cartilage. So when we're talking about these optical sensors that use lasers, things that interfere with those lasers are your bones. So that's a great place to put that type of sensor because it's mostly cartilage. You also have different types of biometrics that you can capture. We all know that the tympanic membrane emits your body temperature. It radiates your body temperature. You can obtain your temperature in a way that you can not do on your wrist. It's also unique because it's exposed to two different environments. It's sitting in the ear canal but also exposed to the outside world. Hearing aids can be a tremendous biometric collection device. They are not intended to displace doctors but instead augment what the doctor does by capturing that data and then alerting you to things that you might not be even aware of within your data. It may detect that you have this irregular heartbeat through the EKG monitor, for example. This whole notion of these things becoming life-saving devices as well as improving your hearing.

Biometric Data Visualization Today

This data will be visualized through different apps. We're starting to see this happen with Starkey and what they are doing with Livio. We're starting to see different ways in which they are utilizing the data that they are capturing through their sensors, and then visualizing it through their app interface. They are actually "gamifying" the process for the user with set goals: exercise for 30 minutes, stand up 12 different times throughout the day, etc. It is combining that with all the acoustic data through the hearing aids to create the "Thrive Score." I think we're going to see more things like this to encourage healthier lifestyles.

Personal Health Data Repository

In much of the same way that we saw the Bluetooth hearing aid become enabled by Apple, I think we will see the same trend again. Bluetooth enablement allowed for the companion apps. All of the different hearing aid manufacturers now have different companion apps that work in conjunction with their hearing aids. Apple, through its Health app and its affiliate software development kits, allow us to capture and store more types of information in your Health app. Whether it be your full electronic medical records, you have this data repository of your health information. You'll then be able to share it with your doctor. "I've been feeling sick. Here's my health data from the last two weeks. Can you please let me know if I should come and see you, or can you prescribe me something?" That's the future Apple is facilitating right now. Apple's software kits that feeds into its Health App include the ReasearchKit, CareKit and HealthKit. 

Figure 4. Apple Health App.

In Figure 4, is a side-by-side comparison. On the left side is my health data without an Apple Watch. On the right side, is with my Apple Watch. You can see there are additional line items when you introduce the technology with an Apple Watch. I think this will be the same trend as hearing aids become more advanced. This is the future that I am imagining. When we think about hearing aids, I think this is such a compelling case, in my opinion. The message that you can hear and live better through the same device. A great example is the country of Singapore which was agreed to purchase Fitbit fitness trackers for its citizens. We can see this trend to live a healthier lifestyle take off.

In Summary

Today's hearing aids are at the forefront of hearable technology and cutting edge wearable technology. If a hearable is a body-worn computer that you wear in your ear, then hearing aids are the most advanced in-the-ear computers that we have out there. Because they are computers. Hearing aids will become more robust similar to our phones in several different ways. This new technology will present unique opportunities for the provider to position them in new ways. What we are looking at here is a convergence of needs. It is one solution that does different things. I think it is the most exciting time for this industry that we have ever been in.

Yes, there is going to be disruption. Yes, there is going to be OTC and online offerings. There will be challenges. You are a provider of knowledge assistance. You know more than anyone about how to fit, calibrate, and guide patients through the aural rehabilitation process. Where I think you can set yourself apart is to take it a step further beyond the traditional scope of what you provide from a value standpoint and start to include different aspects that these devices can do. Hopefully, we can start to increase the market penetration of these devices and get people to treat their hearing loss before the seven years average.