Electronic hearing aids have been in use for more than a century, yet in all of the contemporary buzz about wearable devices hearing aids have been conspicuously absent. My personal experience using the new Starkey Halo i110 made for iPhone hearing aids over the past two months has convinced me that this is a technology that will gain very wide adoption over the coming decade. Beyond being able to adjust the devices from an app on my iPhone, which is convenient for the most part, I can stream the incoming audio from phone calls or music from iTunes or even responses from Siri right to my ears. Although there are many headphones that allow you to take phone calls through a built-in mic, it’s polite to take them off when you are talking to a physical person in front of you. Not so with hearing aids. It is an interesting reversal, but in an age where we are listening to remote audio for hours a day, wearing hearing aids is actually a convenience!
First, let me discuss the obvious reasons why these mission-critical wearables are not all over TechCrunch and Mashable. Number one: there has always been a stigma attached to hearing loss. If you don’t understand what someone else is saying, you could be deaf or stupid and likely, dread of dreads, old. Which brings us to number two: most people who wear hearing aids are older. So admitting that part of your hearing range is shot is tantamount to admitting that a significant part of your life is over. And, number three: hearing aids have been fabulously expensive—along the lines of a high-end computer (or now, two!)
Next, let’s burst some of these bubbles. I have worn hearing aids for the past couple of years. I have also worn eyeglasses almost my entire life. I gotta tell you, they are much alike. (Starkey, the maker of the Halo, also make a very minimalist aid, not controllable by iPhone, called the SoundLens.) Before I got them I had spent a few years missing parts of conversations and filling in the missing details through inference. The lapses of understanding—the incorrect inferences—were mostly in the personal sphere. Within business communication, conversations are usually specifically scoped so that your vocabulary of inference is somewhat limited. But in my busy household of five, context varies moment to moment and I found I was missing the beat more times than I wanted to admit.
As far as age is concerned, yes, older people wear the majority of hearing aids, and I am on the young side of that cohort. Currently, 15% of the U.S. population is 65 or older (50 million people) and 26% are classified as Boomers (80 million people between 50 and 68). Removing the overlap, that’s a primary market, in the U.S. only, of 118 million people. That’s a lot of wearables! But there are many younger people walking around with hearing loss as well (see below for more stats on market sizing.)
My friend, the brilliant content strategist Karen McGrane, has written extensively (and amusingly) on her experience with hearing aids under the keyword “bionic hearing.” In her first blog post on the subject, five years back, she wrote, “Wearing hearing aids is just like wearing glasses, except for the part where they cost as much as a used car and you wear them inside your head.” Karen is far younger than I, but she has been wearing hearing aids most of her life and has followed the technology from analog and clunky to digital and sleek. When she described to me what she was looking for in her next pair, it sounded a lot like the Halos.
Starkey Halo made for iPhone hearing aids
Obviously cost is a barrier to wider adoption, so why are hearing aids so expensive? First, they are generally not covered by insurance. Viagra is, but not hearing aids. Go figure.
Second, and this is significant, hearing aids are often bundled with the service of an audiologist and it is not always transparent what you are buying and how the cost is split between the service and the hardware components. Before you start Googling for how to buy hearing aids directly online or at WalMart, it is worth considering a story that Dave Fabry, VP of Audiology and Professional Relations for Starkey, told me during an interview for this post. When he was in private practice, one of his patients was the late inventor and musician Les Paul. For those of you who have never lusted after the signature guitar from Gibson that bears his name, just know that Les Paul was a pioneer (and by some accounts the inventor) of the solid body electric guitar and an innovator in multitrack recording, all of which made rock and roll and what followed possible. He was also, by Fabry’s account, a famously demanding client. After many years of watching his audiologist attach a primitive computer system to his outsize hearing aids to make minute adjustments, Paul asked for the rig to be sent to his studio so he could tune them himself. He was an audio engineer, after all. Finally, after many such requests, Fabry relented and shipped off the unit. Within less than a week, Paul called him on the phone and said, “You can have it back!” He had gained some perspective on the limitations of his own hearing and on the skills of his audiologist. Although he was a genius of sound coming out of speakers, he had a much harder time with the sound coming into his own head.
In fact, one of the first things McGrane told me when I first discussed hearing aids with her was how important the relationship with your audiologist is. My own experience has borne this out. My first audiologist, Abigail Sedenka at Intermed in Portland, Maine, is a model of empathy and articulateness. Her openness makes you want to share your experience in detail. Marc Kuczewski, the head audiologist at Supreme Hearing Aids in Scarborough, Maine, is a perfect example of what I think 21st century professionalism will be all about. He told me during a tune up midway through this trial that he had previously been a programmer and developer but came to audiology because he wanted to exercise his human skills as well. His ability to master the technological complexities of a wide range of digital audiological devices while also being able to assess the human needs of the person sitting next to him is a balance of aptitudes that I hope we learn to teach in schools. Fabry had done an approximate fitting in absence of an audiogram and it turned out to be overcorrecting in the midtones. Muczewski had the benefit of the audiogram and I walked out of his office feeling like my strings had been tuned. The new economy will have to find ways to value these skills along with the technology they enhance and enable. For now, audiology is an interesting example of how humans can learn to mediate technology for other humans to everyone’s benefit.
What most hearing aid manufacturers do is to expose a very limited amount of control to the user (usually volume and switching between some number of pre-set modes) and then they exposes a much wider set of controls to the audiologist (setting the frequency bands and programming the presets.) The new world of app and iPhone-enabled hearing aids changes that somewhat, but the basic outline of that separation remains intact. Too much user intervention in the moment-by-moment adjustment process is like executing too many trades in your investment portfolio—the returns diminish.
What then, is different when you control your hearing aids with your iPhone? The most important thing is that you gain visual feedback about your personal audio system. Users control most contemporary digital hearing aids with little tiny buttons on the little tiny aids themselves. Over time you get good at making little subtle motions near your ears to surreptitiously nudge the volume higher or switch into the restaurant mode. But sometimes you might be uncertain about how your aids are set at a moment where direct adjustment might be awkward. Depending on your social circles, there might be times where pulling your iPhone out of your pocket can seem rude, but if you are trying to be discreet the iPhone offers much more cover than manually-adjustable aids. That awkwardness—that need for discretion—is something that all hearing-aid wearers feel to a certain extent, but it is diminishing as acknowledgement of how pervasive some degree of hearing loss has become.
According to the NIDCD approximately 15 percent (26 million) of Americans between the ages of 20 and 69 have high frequency hearing loss due to exposure to loud sounds or noise at work or in leisure activities (i.e., heavy metal or EDM concerts!) In 2010, the CDC reported that as many as 16 percent of teens (ages 12 to 19) reported some hearing loss that could have been caused by loud noise (i.e., Beats by Dre, um… Apple!) Hearing loss of more than 25 dB is estimated to exceed 700 million worldwide by 2015. And for every person who wears hearing aids, there are at least four more who could benefit from them. By age 65, 1 in 3 people have hearing loss. At this rate, that will be 1.5 million new customers a year.
One of the things that caught my attention when I was considering getting my hearing evaluated was a growing body of research exploring the possible connections between hearing loss and the onset of Alzheimer’s and other dementias. A study last year in the Journal of the American Medical Association titled “Hearing Loss and Cognitive Decline in Older Adults” reported that “ Hearing loss is independently associated with accelerated cognitive decline” in older adults of a mean age of 77. Fabry clarifies that “there is a correlative–not necessarily a causative—relationship between untreated hearing loss and cognitive decline.” He went on to say that “This is an important first step in raising awareness for the importance of hearing and hearing aids.” On a purely intuitive level it is easy to understand the “use it or lose it” rationale behind a lot of recommendations for how to lower your risk of dementia, and this risk factor falls in that category of preventative measures. Of course, the major motivation for treating hearing loss is to improve one’s quality of life in the present.
Along these lines, it is striking, according to Fabry, that 60 percent of the people with hearing loss are either in the work force or in educational settings. He pointed me to a study titled “The Impact of Untreated Hearing Loss on Household Income“ which shows that “untreated hearing loss results in a loss of income per household of up to $12,000 per year, depending on degree of hearing loss. For the group with the most severe hearing losses (10 percent of the total), the income differential between the aided and unaided groups is $31,000 a year. For the 24 million Americans with untreated hearing loss, this equates to $122 billion in lost income, due to underperformance on the job.” When you look at the data, there is a linear relationship between hearing loss and household income. This is a big problem both in terms of economic impact and national health, so it is natural that money will flow in the direction of a widespread solution.
Once you are on the other side of the divide, you begin to notice how many people you meet are not hearing everything you are saying! The world is filled, in fact, with people who are faking it. Maybe you are one, or your boss—or your husband or wife? It doesn’t need to be that way, and I think that the iPhone connection is one very promising vector for making hearing aids more of a socially accepted form of technological augmentation—like the iPhone itself—than stigmata of disability.
As far as the user experience of the Starkey Halo’s themselves, I can report that the i110, which is the high-end of the line with 16 distinct frequency bands that can be adjusted, has vary good fidelity, especially for speech. Birdsong in the morning can be particularly thrilling. In general, the sound has a musical quality, occasionally with a noticeable touch of reverb. The UX of hearing aids, McGrane pointed out to me, has traditionally been quite bad, from the sound quality itself to the frequency of needed repairs and even to the design of cases to hold the devices themselves. Starkey has improved on these issues with the Halo, but the iPhone app itself—your actual interface to the aids—could use some help.
Starkey TruLink app for iPhone
There are many app makers in the world and few high-end hearing aid manufacturers, so this is a bit of a quibble. I asked Fabry and he told me that there are no plans to open the devices to third-party apps at this time, nor are there any immediate plans for support of Android devices. Fabry did not say so, but I suspect that Apple has some very specific limitations in place built into its agreement with its made for iPhone manufacturing partners.
Although Apple lists seven distinct compatible devices on its iOS hearing aid page, (Audibel A3i, Audigy AGXsp, Beltone First, MicroTech Kinnect, NuEar iSDS, ReSound LiNX and Starkey Halo) Fabry tells me that there are actually only two distinctly different made for iPhone products on the market: Starkey’s Halo/TruLink and GN ReSound’s LiNX. Beltone’s product is a rebranded version of the LiNX and the other four are rebranded versions of Starkey’s TruLink. All of the Starkey devices use the TruLink app and Resound and Beltone use color-branded versions of the LiNX, and truthfully both apps are quite similar. This is probably a reflection of the limited nature of the APIs that Apple has made available. As with all things Apple, this limitation is supposed to assure the quality of the user experience, but I am hoping for some more innovative functionality from Apple and its partners.
The easiest way to see the raw APIs that Apple provides is to see the native iPhone interface itself. Nobody mentioned to me the fact that Apple has a basic way to access accessibility functions in iOS—to triple-tap the home button—I just stumbled upon it one day. The control screen for the hearing aids allows you to set the volume, either left or right or both together, set the mode (normal, restaurant, music and car are the defaults) and access the Live Listen function, which turns your iPhone into a remote microphone (very useful in noisy settings where it is impractical to move physically close to the person speaking but you can push your phone a bit across the table.)
Starkey gives you access to Live Listen through the Microphone function in its TruLink app. With LiNX, this is only accessible through the native iPhone controls. There are two additional related features that both apps expose beyond what the native controls offer. Both apps give you the ability to make a custom sound adjustment and then save it as a geofenced preset. In practical terms, this means that if you are in a noisy restaurant and you need to raise or lower the volume on certain frequencies to be able to understand your dining companion, you can make an adjustment and save it to that specific geographical location. Then the next time you walk into that restaurant, the adjustment will automatically be made for you. The way TruLink and LiNX instrument these adjustments is different. TruLink has what it calls a SoundSpace interface (see image above) that lets you “simultaneously adjust 64 hearing aid parameters in real time with a virtually infinite number of unique settings to match their individual listening preference.” ReSound, by contrast, gives you simpler bass and treble sliders. Neither is ideal, because what you really need to do is create an adjustment curve, but the more minimalist LiNX interface at least gives you two points to adjust instead of one. With the SoundSpace interface I am often not able to make an adjustment that definitively sounds better and I often find myself giving up. (See Les Paul’s experience above!)
The geofencing adjustments are a cool idea in principle, but really they are a good use case for machine learning and AI below the level of the user’s conscious control. I want to be able to hear in a crowded restaurant, but I don’t want to futz. What I have found myself wanting is a display that shows me the sonic characteristics of the space I am in and then suggests curves to improve the sound balance. Eventually you would just trust this “audio assistant” to take care of things for you. For the time being, ReSound’s approach (at least in terms of its app) of less-is-more may well be superior, but down the rode we will want to do more—but pay less attention.
I have not tried the ReSound LiNX devices personally, but on the hardware front, Starkey claims some advantages. One of the important UX decisions with the Halo was to use a larger “13″ battery vs. the standard “312″ to give the device more streaming time. It makes the devices a bit bigger than ReSound’s solution, but Starkey’s Fabry explains that this provides more run time. The tradeoff, in my experience, is well worth it. [Update: In an email from ReSound, the company characterized Starkey’s “stated increased battery life or stream time [as] reportedly minimal.” There are so many variables that determine battery life, that extensive testing would be required to substantiate either claim.] Another helpful feature is TruLink’s adaptive car mode that optimizes settings automatically when your iPhone’s accelerometer detects you are going more than 10 miles an hour. ReSound uses Apple’s default car mode that you need to switch manually. Starkey also claims that its Voice iQ2 is the industry’s most well evidenced noise reduction algorithm. Sound quality is the most subjective of attributes for hearing aids and ReSound makes its own claims based on third-party research for the LiNX’s sound quality being most preferred compared to its (unnamed) competitors. I will be writing up my own hands-on comparison, but for now, let your own ears be the judge.
There are certainly improvements to be made on the hardware side as well. If I don’t restart my iPhone each morning, sometimes when I power up the Halos they don’t pair properly with my phone via Bluetooth. The audio quality of speech is quite good with the Bluetooth streaming, but music can be a challenge. Compared to my preferred RZA Chambers by RZA Premium closed ear headphones from WeSC, the in-ear experience is thin, glitchy and easily distorts at even moderate volumes. Both of these are properly more about the fickleness of Bluetooth and both will likely improve as that standard evolves, but the convenience of streaming is somewhat undercut by the less than completely reliable connectivity. Further, Starkey’s decision to not have any physical controls on the device itself can cause problems if your iPhone’s battery dies at an inopportune time. This has not been a problem for me, but some users may want physical controls on the device as a backup.
BioSport In-Ear headphones from Intel and SMA Audio
Two more additional points to consider. First, although controlling hearing aids from an iPhone is mostly better than tapping on your ears all the time, being able to make adjustments from your wrist, as in iWatch, would be far better. The smart watch will be a great interface for these kinds of wearables. If the API were open to third-party developers, we might have a Pebble app today, but I guess I will have to wait on Apple for that further convenience. Second, Fabry and I discussed how the ear might likely be a better site for biometric sensors than the wrist and, lo and behold, just yesterday Intel and SMS Audio announced the BioSport In-Ear Biometric Headphones to “Optimize Workouts for Ultra-marathoners, Aspirational Exercisers and Everyone in Between.” It is easy to imagine something like the BioSport merged with the Halo as a kind of general-purpose augmentative ear-ware with 100% cool and 0% stigma.
Hearing is so important to the quality of communication and ultimately to the overall quality of people’s lives. There is so much pleasure in birdsong and music and in the exact tone of another person’s voice. But there is also so much economic value to be gained from improving human communication through augmentation of hearing. Fabry stops short of calling it “bionic hearing” but it is clearly going in that direction. In the future, we will all hear better.