 Hi everyone, so I'm David Allen, a senior research audiologist here to speak about. We started off with barriers and facilitators. I decided I wanted a bit more of a potentially interesting title. So I've titled this talk, Want versus Need, Why Hearing Providers Choose Connected Hearing Services. But also I guess we're sometimes talking about why they don't choose them as well. So the objectives of this session is a couple of them. Firstly, to have a chat about some different kinds of connected hearing health services and then to explore some of the reasons why hearing clinicians and other staff either choose to use or choose to reject connected hearing services. So before we get into all of that, we really need to understand what are connected health services. Now, the definition that I really like is one that the ISO put out for telehealth. So telehealth is the use of telecommunication techniques for the purpose of providing telemedicine medical education and health education over a distance. So we're talking particularly in hearing health there about delivery rehabilitation, but also health education. So providing the informational counseling that we do. But a really important thing in that definition is that it refers to any health service where the client and the clinician are not co-located and then the communication between them is happening using some kind of telecommunication system. So let's have a look at what happens in Australia. It's the area that I know. There are various connected hearing health services that are currently being used in Australia. Some of these you may know. So we see connected hearing services used a lot for screening. So TelScreen 2 is a great and now example of that, which was developed to be able to be delivered over the phone or over the internet so that we can screen people for hearing loss. We also see remote apps for hearing aids. So we're a hearing aid that's connected to a usually a smartphone or a tablet can be remotely adjusted. And a lot of those also have a building method for the clinician and the client to be able to talk to each other. A lot of companies also provide a web chat service often on their websites for information maintenance inquiries, you know, those kinds of informational kind of interactions. Although we are seeing some clinical interactions being done over those as well. There are a few entirely remote rehabilitation services. So right from remote assessment where the client and the clinician aren't in the same room through a hearing device fitting and then assessment of that fitting or follow up of that fitting without the client and clinician ever having been in the same room. We also see a reasonable amount of usage of connected hearing health services in areas where access is limited. So in Australia, the most obvious example of that is into our remote first nations communities, although it is also done in areas where maybe specialist services need to go into a regional town or something like that. So we have all of these various services, but one of the things to know about them is that they tend to be pretty niche. They haven't been widely adopted in most places. The rates tend to be really low. That's a bit of a concern because we know that connected hearing health supports clients. There's really strong evidence that it facilitates communication between the client and the clinician and that's both information going safe from the clinician to the client, but it also allows for information to go back the other way. So for the client to contact their clinicians in a new way, often in an asynchronous way so they can send the message or get in touch whenever they want and wherever they want. We also know that it improves self-management. So this improved access to information and information, as I say, in a way and at a time that suits the client can really support self-management for the client, can help them to actually be able to kind of troubleshoot their own problems and manage their own issues. And as part of this, it also strongly improves empowerment. So it gives clients a way to really engage strongly with the health service to be able to take some control over it and to guide the service in a way that they wouldn't have been able to do otherwise. So if we know that the benefit is there, why is usage generally so low? Well, I'm a researcher and I work at a research organization. So what we did was to do a research study. And our research question was essentially what are the factors that go into whether staff choose to use or not use connected hearing services. We conducted a survey of 132 staff of Hearing Australia. There were primarily clinicians. For those of you who may not know, Hearing Australia is an Australian government-owned hearing services organization. Happens to also be the parent organization of now. And they have over 100 or several hundred sites around Australia which see more than 2,000 people every week. So a very busy clinical service. We asked about three connected hearing health services that were active within Hearing Australia at the time. So these weren't new things. They were things which were established within the business. Its usage rates were highly variable, but they were things where there was training available. There were resources available. People could actually access them and use them. We asked all of our respondents, does your center deliver that service? What currently works well or would help you to use the service and also what doesn't work so well or stops you from using it? So quite clearly we're looking here at facilitators and barriers. We then collated all those responses, brought them all together and analyzed them using thematic analysis, which is a well-known qualitative technique. So when we brought all of these responses together, it really came down into what staff needed to know. And I've framed these as different questions that the staff were asking themselves about when they were making the decision to use or not use the connected hearing health service. So firstly, training. Do I have the skills to use this service and to use it comfortably? And it's not just about being able to do the day-to-day nuts and bolts of sending messages or enrolling clients into the system. It's also about having the skills to be able to troubleshoot, to be able to train a client to use it as well, and to be able to do that with a really wide range of abilities in the client base. So it's not just, it's not enough just to have a base level of training that has to be quite a significant amount of training and skill to be able to use these services effectively. In addition, even if we have a single, highly trained staff member, they need to know, are there enough people with the right skills around me? So it's not enough just to train the clinicians in a service. We also need the front of house staff or the reception and support staff to understand that the services exist and be able to talk them through and be able to assist with their usage. If there's a call center or an information line, then those people need to understand the service. And we also need strong IT support and easily accessible IT support people to be able to then support the infrastructure which goes along with these telecommunications-based services. Time is always a really big thing. Clinical time is tight. We have very busy clinics. And so clinicians in particular needed to know that they had enough time to be able to use the service. And it wasn't just, as I said before, it wasn't just about the usage itself. It was also having enough time to effectively set people up, train them in how to use it, and then support them to troubleshoot any problems that might have arisen. We really need to have effective technology. So for the most obvious technology that might come to mind here is fast internet connection and for video conferencing based systems, yes. Fast internet access, absolutely vital. However, that's not the only technology that's necessary and it's not the only technology that really needs to work. So if we're looking at, for example, the smartphone apps, if a smartphone app only works on iPhone, then for a client who owns an Android smartphone, that technology effectively doesn't work. And so having services that were available in various different ways and on as many different devices as possible was really a component of making sure that the technology itself worked effectively. Usability was a really big concern and that's making sure the service works easily both for me as a staff member and for my client. We actually had a really great example of this. There was a service which had seen some usage and particularly with people who were very comfortable with it. They used it quite effectively, but when it was first rolled out there were some concerns about the usability. It was a little bit clunky to get off the ground and what we found was that it really wasn't used in the organization particularly effectively as a result. So these are all pretty obvious things. The last two are a little bit different. So before, so far we've been talking about the service and the kind of service little issues. Now let's talk about the personal question of the right client. Will this client or my client be able to benefit from this service? There is a perception whether real or not the some clients won't be able to engage with tele services or with connected hearing health services. And so having an understanding of who the right client is and who's likely to be able to benefit is really important. And finally on the clinician side or the staff member side, the staff member needs to believe that the service is going to help their client. They need to have sufficient evidence whether that's research based evidence or a manufacturer's white paper or even anecdotes from other colleagues that the service is actually going to work and that it's going to be of benefit. If they don't believe that it's going to be of benefit then they're not going to use it. They're going to spend their time and energy on something else. So those are the things that staff need to know but they weren't all of our findings. As we were going through the data we found some really interesting little nuggets that I'd like to go through as well. One of the things was that a lot of the staff that we spoke to talked about connected hearing services as an alternative to traditional services. It was either you delivered service in a traditional way or you delivered service in a connected way. One of the things that we found and have found in other work as well among staff who really effectively use connected hearing health services is that they don't see it as an alternative through traditional service. They just see it as another way of delivering the same high-quality service that they've been delivering before. So it's a different channel. It's not an alternative. One of the things that really kind of gave us some confidence in these results is that it didn't matter what kind of service we were looking at the same kinds of problems arose. It didn't matter whether we were looking at a smartphone app or a video conferencing appointment system or any of those kinds of things. We saw the same issues around training, the same issues around time, the same issues around staffing. So that gives us some confidence that this model is something which is not only applicable to the services that we studied but also applicable to future connected hearing health services potentially even some that we haven't thought of yet. Newer interventions tended to have more issues and more varied issues. So this seems really obvious when you think about it but when something was first introduced there hadn't been the chance to try and iron out the kinks yet. And so that's something to be aware of when we're implementing new things into our hearing centres is that we're going to get problems. We're going to get complaints. That's okay. The important thing is to address those and to work through them. And if we can do that then we will likely get good outcomes. Many staff felt that most clients were not suitable for telehealth and the biggest reason given here was around technological competence. However, these data are a couple of years old now. We know from back in 2017, 2018 from a Deloitte study here in Australia that at the time about 80% of adults over 65 own a smartphone. I can't speak to how well they may be able to use that or what different kinds of things they might be able to do with that smartphone. That's somebody else's research project I think. But we do know that a lot of older adults in particular have access to the technologies that are going to enable them to engage with connected hearing health. So if we don't make the offer as clinicians then I really think we're doing our clients a disservice. The final thing and this is where I think the title of this presentation the want versus need came up is that many clinicians just didn't feel their clients needed the service. They maybe wanted to use it but they didn't feel it was necessary. We got comments like it hasn't been needed. There's been no clinical need. There's been insufficient demand in this area. And then COVID happened. There was a really increased focus on contactless delivery to reduce infection risk. Understandably so. And there were also temporary regulatory changes particularly in Australia but also around the world to facilitate contactless delivery. And what we saw was this idea of well I want to use connected hearing health but it's not really necessary. It really became a need. And so you'll see on that very narrow graph on the right there we were doing some work to try and get more people using a particular connected hearing health intervention service. And you can see that little hump there in December and January as our intervention kind of came in and peaked and then the effects dropped off. And then COVID happened and we went from a tiny fraction 5% up to 40% in the space of a couple of months where there is a demonstrated need that led to change. And we need to change the way that we talk about these kinds of things. This is an option which is going to be really effective for some of our clients and we need to give them the opportunity otherwise we are doing our clients a disservice. So I think there's quite a lot of opportunities here. Most obvious connected hearing health services can support clients and clinicians. There's a real opportunity to roll them out more effectively into our organizations and get that work happening get it accessible to people. From some of the work that we've done we now know what needs to be addressed in order to support uptake. We know what the likely problems are going to be and we can develop really effective and really targeted change management processes to improve our implementation. And also, I mean every cloud has a silver lining the current situation with a global pandemic this is actually a really significant opportunity for us to establish these services as a part of our ongoing service delivery. We don't have to replace everything that we do by connected hearing health. We can use a hybrid model but this opportunity isn't going to come up again we hope but we do have a real opportunity here to embed these services into our business as usual. So a huge thank you before we go to Q&A I'm hoping for some interesting questions. I'd like to say huge thank you to the research team who did the majority of the work underpinning all of this also to our partners in the business at Hearing Australia and all of the Hearing Centre staff who took part in our study. This kind of work going into Hearing Centres asking pertinent, impertinent questions doesn't happen without strong relationships and so a huge thank you to everybody who engaged with us and made this happen and obviously a huge thank you to Hearing Australia as well for allowing us into their clinics and also for funding this study.