 Hello everybody. I'm excited to present at the Internet and Audiology conference and I'd like to talk about the project we are doing at home testing by co-producers. But I'd also like to start about fixing Internet and Audiology. And there I don't mean the conference. First of all, I'd like to thank the organizers for organizing this great conference and the way that we are using innovative mediums to share information, have discussions and to, I hope, learn a lot of things in the next days. So what I want to talk about is Internet and this I want to do as parents and audiologists and share some of my concerns before going to the second part of this presentation and zooming into an audiological project. So if there are questions, you can send them to internetaudiology.com. This is an email address made privately by design. And the reason that I want to share some views about Internet is that I think the ultimate hallmark for quality is that if the next patient you see would be a family member or a friend and you don't change the way you're doing or providing your care, then you're really providing the care to the best of your ability. And when using Internet, I have some concerns for instance for my children or for family and friends or for myself, which I think needs change and which I also think needs change for professionals to be able to responsibly use the Internet for providing hearing healthcare. Okay. So this first part of the presentation are my personal views on Internet. And at the same time, I believe that we can do remote measurements in a responsible way if we keep the risks as low as reasonably achievable. And I guess that context information is really important further to make this point, but also if you want to scale up remote measurements to use it globally and maybe to use it on persons, you don't know in person. What's also important is that the tools that I'll use during this presentation developed by Cochlear and by EarX have been developed for screening purposes and may not maybe be ready yet for this larger vision about remote hearing care. So I'd be aware of these limitations. Why do we need at home testing? Well, there's at least 1.3 billion people that suffer from some degree of hearing loss. And if we want to provide them optimal care, I think we cannot use the conventional system we use today. Because there's a lack of resources in numbers of professionals that we would need to provide care to everybody. Also the equipment we need. But there's also barriers to seek help. For instance, most adults with the hearing loss wait on average 7 to 8 years before seeking help or starting to use a hearing aid. And another thing that's getting more important these days is low touch solutions so that a visit in a hospital if you can prevent it is preferred. And probably there are many more motivations for at home testing. These three were most important for me in the last two years. And how can we provide this at home testing? Then we need virtual and hybrid care via digital platforms. And where I say digital platforms, I mean internet. So what we need is internet suitable for medical purposes. So the question is, does internet need a fix to transform to a medical internet? And there's a couple of questions that you can ask yourself. For instance, do you entrust your personal information to the current online players? How about the risks for bias? Many books written about this. For instance, the weapons of math destruction about what the effects are if algorithms are used for decisions. But if these algorithms are not transparent or maybe trained on biased data. Then there's privacy, which is of course really important. And I used to believe that if you solve this at the individual level, it's fine. But just to give a personal example, I've been using the Google engine for a couple of years. And first, I refused to share my personal information with Google. And every other day, they reminded me, do you still not want to share your personal information to enhance your search services? And after a couple of months, I surrendered because I was fetched up with always refusing cookies. And since the day that I accepted those cookies, they never sent me a reminder if I wanted to continue sharing my private information. And that brings me to a couple of other important issues like the balance of power and net neutrality. The balance of power is that the problem that a few very powerful players can more or less design the rules how we play it now. And I think this imbalance is a risk since it may prevent us from taking the interests of all stakeholders into account. So all internet users and medical use, of course, the patients, the clinicians, but also society at large who is paying for part of these services. And what's also important is net neutrality. And then I mean access for instance to services. And some of these dominant players are so powerful that they can even refuse the president of the United States to make use of their services and ban somebody's Twitter account. So imagine that there's a critical service, healthcare service, and it's not everybody has access to it. And if not everybody has access to it, then it's still important that who is making up these rules and who is also safeguarding these rules. And how can we deal with sources of information? Who can you trust? And I admit it's getting more and more difficult these days when there's people sharing conspiracy theories via the internet about anti-flexes, et cetera, et cetera. And there's also a lot of great scientific talks. It's a lot of information and it's so much information that you need support or help by others, I think, to find the information that's suitable for you. And then there's also the question, can you even choose the room to interact and also influence the way how you are treated? So that services are provided tailored to your needs. But also, yeah, maybe the cost, if remote care would be cheaper, can you still refuse for remote care if you don't feel comfortable with the solution? And imagine for instance that schools, hospitals, and highways are all assets from big corporations and they are used to maximize shareholder value. How would that society look like? And now just make it digital, I think that's already happening. So we have to think about how to design the digital equivalence of schools and hospitals and ways of transport and communication. And it may add also the aspect of digital well-being. And besides a physical well-being, due to the importance of digital presence, I think if your instance are followed by internet trolls that may affect how you are feeling and may affect your mind and physical body. So we have to think about how to deal with these threats maybe for your digital well-being or the risk of living in a very tiny digital bubble or oblivious to maybe the lives of others. So how can you give a good assessment of the situation of a patient in front of you if you do not know much about that patient and about maybe the bubble that person is living in? So I believe that as long as a few actors dominate social media and the internet, we cannot develop a secure and neutral internet suitable for remote medical care. So we will need to go to an internet that shares sensations very rapidly across the globe to one that shares sensible information. And to do so we need to take the interest of all stakeholders into account. And if we zoom into the problem of the problem of developing remote care, then for remotely performed hearing assessments, we do need to know the context and the user who you're collecting data from. So in the context, I mean that a hearing test, its outcome may be invalid if the measurement is done in a noisy environment or if the procedure was not clear to the user or there was a lack of attention, faulty hardware, etc. There's many reasons we can think of why a measurement is invalid. And that's something that's important for all medical domains, the context for where the measurement has been performed. For instance, in monitoring vital science, an increased heart rate may indicate that a person is at risk when the person is in a hospital bed. However, when that person is at home and climbing a stair, well then an increased heart rate may not be so big of a deal. And I'm sure that this context is collected by players like Facebook. For many people, a lot of things because we sometimes share it purposefully and sometimes we share it without being aware of it. Then the user, for instance, if you diagnose a hearing loss, there's many factors that are important. For instance, age or genetic disposition. And the consequences of somebody's hearing loss, of course, depends very much on how that person is living, what desires that person and ambitions that person has, and also where that person is going to do the things he or she wants to do. That, again, goes for many medical domains that personal information is needed for interpretation, and not only for the medical care but also for the social care. And so it will be important for both healthcare and social care organizations to be able to share information to provide optimal care. And here again, I'm sure that Facebook and others have access to a lot of vital personal information. So now here's then the ultimate test that I would like to invite you to try a remote measurement via headset yourself, to experience it, to see how it goes, and try to imagine for yourself what it could mean for one of your patients or maybe family members. And imagine what a colleague of you would need to properly assess the measurement. So I'll provide you a link so that you can do the test. The outcome of the test will only be visible to me or persons at trust. And if you are privacy sensitive, you may choose just to share a phony name and a phony phone number. And the objective for you to learn would be to be able to explain the digits and noise test. Which will be explained also on this page, but I'm sure that there's a lot of people that would need another set of instructions to properly do the test, while the other objectives are already mentioned. And these kinds of tests, I think, might fit into a digital care pathway where the patient can test at what time he or she wants to do the test, maybe also at what location, but that will depend probably also on the location, where a local clinician can assess the outcome and maybe provide care or counsel, or can seek help from a remote expert for further advice or maybe analyzing some trends in the data. And to do this on a large scale, we need algorithmic support and automation of a lot of the tasks at hand. Well, this model may work, but I believe we need to address a lot of concerns before we can really use it. So here's then the project, part two of the presentation, and it's a project about at home measurements, which I do with a couple of colleagues, Wendy Lukas and Doreen. Again, you can still use the email address for your questions. And here are some examples of at home measurements of audiometry in person with profound hearing loss. So there's a silver lining here that persons with this profound hearing loss do have possibly less problems with environmental noise that has less effect on the hearing test. But of course, many other factors may still affect the outcome, like learning the test procedure, circadian rhythm, attention for the test, fatigue. And by collecting multiple measurements, we would like to try to be able in the future to reduce unnecessary variability, increase maybe the test accuracy if needed. And we may be able to assess trends that are unseen in a single measurement. And what you see here in this graph is an example of circadian rhythm by plotting the core body temperature that fluctuates a little bit over time when you're awake. And it peaks after more or less three hours on average in most persons. And that is the moment that you are at your best for cognitive and physical tasks. So that may have an effect, of course, also on the test outcome. What's also important is how people are doing in general. So we want to have some benchmark. That's the reason why we also ask people to fill out questionnaire, where they self-report about concentration and motivation, physical activity and fatigue over the last two weeks. And that's data we can compare with healthy persons and also with people with some hearing loss. And here's the study protocol. What we do is we minister nine hearing test batteries. I'll explain what kind of tests are included in the next slides. We also do this survey about subjective fatigue. And what you see here is how we have made a schedule for the nine measurements. And by choosing these different moments, we can, for instance, have a look at test retest effects of the morning versus within a session by doing two tests in the morning consecutively versus between sessions by comparing the outcomes in the morning at different days. And also we can have a look at, sorry, circadian rhythm by looking at outcome compared between morning, noon and night. And then three months after the start of the measurements, we do again a full measurement, including also the subjective fatigue survey. So what does the test battery include? Well, this full test battery includes six different tests or tasks that we'll explain. But before every measurement, we also ask a couple of questions to assess the state of the subject by how motivated they are now to do the test, also how fit they feel at that moment. And right after the test, they need to assess how much effort it took to do the test. And if they wanted to give up, which is maybe a proxy for the listening efforts they have invested. And the test itself, it's called the remote check, which is developed by Cochlear. And people are asked to make a photo of the area where they're sampling. They also need to fill out two questionnaires, including questions from the SSQ about, for instance, what listening problems they experienced and they realized. They need to do an audiogram, which is done by streaming sound from an iPhone to the implant. And the advantage is that we don't have any problem with calibration because we have well-defined hardware. And another test is the speech and noise. In this case, the digital noise that you will be able to try yourself. And then there's another questionnaire and there's an impedance check. And for the short version of the remote check, we only let people do the audiogram testing speech and noise impedance check. That takes between five and 10 minutes in total. I cannot share yet the results of our study, but I can share some lessons learned. So what we see is that multiple tests a day is possible. Also that you can give the instructions via email and via messengers. And that way you can do a totally virtual assessment. But still it's important we are testing to give the proper instructions and where that person is doing the test. Also, sometimes of technical issues, Bluetooth signal that's, for instance, prone to interference with other devices. We feel that this instant messaging with subjects is really helpful because we can give them reminders to prepare for the next test. But also they can, if there's a problem, almost instantly ask for our feedback and we can just ask them also, for instance, what time they expect to get up. And if that's at seven o'clock and they start the test and what time they start a test that we can stand by during this test. Well, this is questionnaire seems to be sensitive to masochromic fatigue, but it's too early to make definite conclusions here. There's also some constraints. For instance, digital proficiency. I was already explaining it's important to know who you are testing. For instance, we had this experience and we asked people to make a screenshot when they ran into a problem during the test. And then the response was, yeah, what's a screenshot? And we had to first explain how to make a screenshot with your iOS device and then share this photo via the messenger. But that's, I think something we can deal with, that all the subjects so far was almost 80 years old and many older participants have experience as a parent with using these devices within communication with grant children. So far, this test only works on iOS devices. So that means a lot of our patients cannot use this service yet. And we have suffered some technical problems, especially the connection between the iPhone and the local implement processor. But I'm confident that most of these issues will be resolved soon. Well, thank you for your attention. Please let me know if you have questions. And I hope we can also use the interactive session at the conference earlier this year in February. I provided a talk more about ecologically valid measurements, but with also a lot of overlap with today's talk. And I'm preparing a talk more about online tools and resources. So I hope to talk to you again in the future. Thank you for your attention.