Assembling RIC wire and custom hard earmould

 

Assembling RIC wire and p-receiver for Widex Fusion

Assembling RIC wire and m-receiver for Widex Fusion

WidexLink

WidexLink
- a New, Industry-leading Technology for Wireless Transmission

In recent years, we have seen a variety of new hearing aids on the market with different wireless communication abilities. Some offer the possibility of transmitting sound to the hearing aid from a mobile phone, a TV, or an MP3 player. Others hearing aids are capable of exchanging coordination data, and a small number are able to transmit sound to one another.

We believe that the key to new achievements in the hearing aid industry lies in the ability to use a sophisticated wireless transmission technology which will facilitate the coordination of dynamic settings between two hearing aids, high quality transmission of audio from external sound sources, and wireless transmission of data between two hearing aids.

We are convinced that wireless technology is the future in the hearing aid industry. However, the success of any given wireless transmission technology will depend on at least three key issues when applied to hearing aids: Sound quality, transmission robustness, and power consumption.

WidexLink is our new proprietary digital radio frequency transmission technology. The new technology has been designed to provide the highest audio quality and efficiency. WidexLink offers new possibilities for extended bandwidth audio transmission between hearing aids (for example, CROS and BiCROS applications),extended bandwidth audio streaming from external assistive listening devices (for example, DEX devices) to hearing aids, and the continuous exchange of synchronisation data between hearing aids and external devices (Inter-ear communication).

The unique, digital wireless link offers an unparalleled low latency (delay) of <10 ms when transmitting audio. This ensures minimum distortion and echo-free audio quality when direct acoustic sound in the room is mixed with transmitted sound.

The need for a new technology

Today, Bluetooth is probably the most popular wireless technology for transferring data and digital sound between devices. The Bluetooth technology is available in a large variety of "plug-and-play" chip solutions. From an engineering point of view, therefore, Bluetooth is the fastest way to a digital wireless design. However, Bluetooth has some drawbacks which create serious problems in hearing aid applications.


First and foremost, Bluetooth is an extremely energy-demanding technology. The Bluetooth chip uses so much power that it has no practical application in the hearing aid industry. Moreover, even if another chip is used, battery drainage is still very high during Bluetooth transmission. Hearing aid manufacturers are therefore forced to find ways to optimise Bluetooth transmission if the power consumption is to be kept at a reasonable level.


Another serious drawback is that standard Bluetooth has a high built-in latency (delay) of 150 ms when transferring audio through the Bluetooth codec. That is, transmitted sound will reach the ear 150 ms later than the direct acoustic sound in the room. In hearing aid applications, this is a serious issue because the time delay between sound sources comprises important psychoacoustic cues about direction and distance to sound sources. The latency can be reduced by switching off some of the technological features while transferring digital audio, but there is a limit to how far this optimisation can be forced. As far as is known, the Bluetooth latency can be reduced no further than approximately 45 ms which is not sufficient to avoid artefacts in hearing aid applications.

Latencies and artefacts

A small delay of 1 to 10 milliseconds is unproblematic. However, when the delay between transmitted and direct sound becomes longer than 10 milliseconds, artefacts begin to occur. The first artefact to occur will be an audible comb-filter effect. It is called "comb-filter effect" because it filters away frequencies like a comb, making notches in the spectrum. The resulting sound will be hollow and metallic. Above 40 milliseconds the streamed sound will be perceived as an echo of the direct sounds. An additional problem can occur when sound is transmitted from for example a TV. When the delay reaches around 150 milliseconds, which is the default delay with Bluetooth, lip movements will begin to appear unsynchronised with the sound. Thus, hearing aid manufacturers who rely on Bluetooth or another technology which introduces a delay above 10 ms will not be able to avoid artefacts in their applications.

Also included on the list of Bluetooth drawbacks are the relatively large chip size and the high current consumption which are obviously essential parameters in a hearing aid design.

The artefacts that can occur as a result of the delay between direct sound and digital audio stream are listed in the figure below:

Figure 1. Psycho-acoustic artefacts due to latency (delay) between direct sound and transmitted sound.

 

The new technology from Widex has un-paralleled low latency of less than 10 ms between the direct acoustic sound and the digital audio stream. And in CROS and BiCROS applications, the delay is even shorter.

Advantages of WidexLink

It is no simple matter to design a system which can simultaneously maintain high audio quality, low battery drain, and robustness against transmission errors.
Widex achieved these goals by developing a very efficient audio coding method which is custom-designed for use in a hearing aid platform.


It was considered of the utmost importance that the highest possible audio quality should be maintained with the new wireless technology. In order to achieve this goal, several key components of the wireless system were carefully designed. First, a very efficient and robust audio codec (short for encoding/decoding) and radio frequency (RF) transmission system were developed to ensure fast, stable, and trouble-free transmission of sound and data during normal use.  It was a requirement that the digital audio codec be based on a coding principle which will ensure that the signal is perceived to be as close to the original sound as possible.  Another factor in maintaining a high audio quality was a low audio delay over the wireless transmission system.  To achieve this, the digital coding system was designed in such a way that no data would need to be re-transmitted and consequently slow down the transfer of the audio signal as a result.


Ensuring battery efficiency was also a major concern in the design of WidexLink. This goal was achieved through the employment of a very efficient data compression method, and the invention of a new, highly sensitive radio receiver which permits low transmission power.


Robustness was achieved in multiple ways. In addition to the inherent robustness of the audio codec and the radio receiver mentioned above, robustness was also attained by means of a highly efficient channel coding which detects and handles errors quickly and securely.


How WidexLink addresses the key factors will be discussed in more detail below.

High sound quality

Audio bandwidth

Audio bandwidth is one of the key factors in maintaining a high sound quality. Thanks to the new technology in the Clear product range, we are able to offer an exceptionally broad audio bandwidth in models with a Clearband receiver, stretching from 100 Hz to 11.2 kHz for transmitted sound. This is industry leading.

One area where a broad audio bandwidth makes a clear difference for hearing aid users is when they listen to music. The high frequencies provide ambience and brilliance to the sound. Thus, the sound experience will be somewhat richer with an upper bandwidth of 11 kHz when listening to the crispy sound of a hi-hat or cymbals, for instance. Similarly, an audio bandwidth stretching as far down as 100 Hz will produce a fuller bass.

Codec

Another way to maintain a high sound quality is to develop an efficient codec. Digital audio data as we know them from CDs are extremely bulky. It is therefore necessary to reduce digital audio data in some way as the transmission bandwidth is too narrow to effectively transmit the raw audio signal. This is achieved by means of data compression (not to be confused with the dynamic compression of the audio signal in the hearing aid).

Digital audio data compression is achieved by means of a set of complex algorithms called an audio codec.  An audio codec consists of two parts:  encoding and decoding.  The purpose of the audio encoding is to reduce the size of the digital data representing the original signal. The purpose of the decoding is to reconstruct the encoded audio signal in a manner which ensures that it is as close as possible to the original audio signal. This process is analogous to the shipping of a parcel by mail. If you wished to send an office desk from the U.S. to Europe, you could simply place the assembled desk inside a large box and send it. This shipping method would be quite expensive, though, due to the size of the parcel. A more efficient and less expensive method of shipping the desk would be to disassemble the desk into smaller pieces and package it in a much smaller box. The same principle applies to the transmission of digital audio. The cost of sending digital audio is related to its size. The larger the size of the digital audio data, the larger the transmission bandwidth has to be.


Two different compression techniques are typically used in order to squeeze the audio information into a smaller package.  Both compression techniques rely on the fact that audio signals have a great amount of redundancy.  


One commonly used technique is Redundancy Coding. This technique is similar to the process used when computers compress files into ZIP files. This type of compression can be demonstrated by a simple example:

If we need to send the number 1000000, we may compress it to 10⁶.

The compressed number represents the same digits as the original number, but comprises fewer characters. If each character requires four bits, the uncompressed number would require 28 bits (4 bits x 7 characters), while the compressed number would require 12 bits (4 bits x 3 characters). The technique is effective with data where there is lots of redundant information as is the case with digital audio signals. However, the technique has one major drawback; namely that it is relatively time-consuming. It is therefore not very suitable for hearing aid applications where a minimal delay is of the utmost importance.


Another commonly used technique for achieving a low bit rate is Irrelevance Coding.  It is widely used today to create MP3 and other types of digital audio files.  Widex also uses this technique for analysing and compressing audio data in a special part of the codec. .


It is well-known that raw, uncompressed audio contains more information than the human ear can actually detect. Our irrelevance coding algorithm removes all perceptual redundancies by extracting all of the irrelevant audio information which cannot be heard by the listener due to psychoacoustic masking effects in the cochlea. In other words, the irrelevance coding algorithm uses knowledge of masking to remove audio signal elements which are outside the limits of the human auditory system.  


Irrelevance coding relies on a phenomenon known as the Simultaneous Masking Effect. When listening to a soft and a loud sound simultaneously, it is often difficult to hear the soft sound because it is drowned by the loud sound. The masking effect is largest when the soft sound is in the same frequency range as the soft sound (Moore, 2006: 66). This psychoacoustic phenomenon is very useful vis-à-vis audio data compression. The irrelevance algorithm utilizes knowledge of this psychoacoustic effect to remove softer, less dominant sounds which will be masked by louder, more dominant sounds, from the audio signal.


Basically, our irrelevance algorithm reduces the amount of audio data that needs to be transmitted wirelessly by removing sounds which would not be audible to the listener in any case. And by removing sounds in the audio signal which the listener cannot hear anyway, while preserving the sounds the user can hear, the audio signal can be reduced significantly in size without compromising the high sound quality.

Safe digital transmission

Channel coding

An important aspect to consider when sending any type of digital data over a wireless connection is the potential for errors induced by radio frequency interference.


Errors will occur from time to time with any kind of transmission and especially in wireless transmission. The distance between the devices may change, the orientation of the antenna in the controller might be altered, or interference from radio noise might disturb the connection. Such errors must be handled effectively to minimise the inconvenience caused to the hearing aid user in the shape of crackling, dropouts in the sound, etc. Therefore, in order to prepare the audio data for transmission and ensure the integrity of the transmission with respect to correct receiver as well as the quality of transmitted data, channel coding is introduced.

Error detection and handling

The main task of the channel coding algorithm is to provide a method for ensuring that the digital audio signal which is received is indeed correct and error free. A common and very basic way to do this is to calculate what is called a checksum on the basis of the compressed data. The checksum is enclosed in the shipment alongside the data. When the data are received at the other end, a comparison of the checksum and the data is conducted to determine if any errors have been introduced into the digital audio signal.




Figure 2. The data in the shipment are compared
to the checksum on arrival to determine if any
errors have arisen.


However, a checksum will only establish whether or not an error has occurred. It does not provide a solution to how errors should be handled. A major advantage of Widex' channel coding algorithm is that, thanks to a so-called error corrective code, it ensures that a restricted number of errors can be both detected and corrected.

In a Bluetooth transmission technology, for example, the channel coding will by default ask for a retransmission of data which did not pass the receiver's error checking algorithm (www.bluetooth.com). Since retransmission requests will cause an extra delay whenever the system has to wait for the repetitions of the data to arrive, such a method is not a very good choice in a hearing aid application.

Another method involves the removal of audio data packages which contain errors. This method is for instance used in connection with DAB (Digital Audio Broadcasting). DAB-receivers cannot request a retransmission of signals vitiated by errors. Errors in audio data are simply handled by making dropouts in the sound, resulting in there being no sound playback when errors occur. An error handling method which results in clicks or dropouts in the sound is obviously not very suitable for a hearing aid application either.

Widex rely on a special channel-coding technique which is based on the principle of Graceful Degradation. This technique has none of the unfortunate by-products (long delay and dropouts) mentioned above. Instead, it provides a smooth, seamless listening experience for the hearing aid user.



Figure 3. Widex's channel coding algorithm
can both detect and handle errors.


Widex's channel coding algorithm has been designed to ensure that a small number of transmission errors can be corrected by the algorithm itself. A larger number of errors will be handled by means of the above-mentioned Graceful Degradation-based technique. This technique ensures that a large number of errors will not result in any abrupt changes in the output signal, such as dropout or cracking, heard by the hearing aid user. If the errors are too numerous for the algorithm to be able to correct them, the result will be a gradual fading of the sound. While transmission is interrupted, the HA will switch to the Master program. When the quality of the transmission channel is good enough to allow audio transmission once more, the sound will gradually fade in again to provide a nice, smooth listening experience for the hearing aid user.

Figure 4. Summary of three methods for error handling in connection with digitally transmitted data.

Digital Audio Transmission by WidexLink

 

The WidexLink technology makes it possible to minimise the amount of data that needs to be transmitted in order to ensure a high quality output signal. This is essentially possible thanks to the identical audio generators in the encoder and the decoder. More specifically, because the WidexLink encoder and decoder both contain identical synthetic audio generators, it is not necessary to transmit the original signal, or even the synthetic signal. All that needs to be transmitted is information about the discrepancy between the original sound signal and the synthetically generated signal. A more detailed discussion is included in the sections below.


The WidexLink encoding procedure can be divided into five main stages. In the first stage, the original audio signal is compared with a synthetic signal generated by a Synthetic Audio Generator. A Discrepancy Analyser generates information about how close the synthetic sound is to the original. A perceptual model is then applied to determine if discrepancies are audible or not (irrelevance coding). To keep the amount of data to a minimum, only audible discrepancies are allowed to influence the sound generation process. Next, the best approximation to the discrepancy between the original sound and the synthetic signal is retrieved from a large number of synthetic sounds stored in a Sound Sample Archive. And finally, information about which sample is the best approximation to the discrepancy between original and synthetic signal is transmitted to the decoder.

Figure 5. The WidexLink encoder principle.


With WidexLink, the sampling rate is 25.44 kHz, which means that the above procedure is repeated 25,440 times for each second of sound. This enables us to exploit the fact that there is typically not very much variation from one sound sample to the next to generate an increasingly accurate synthetic representation of the original signal.


The first time a discrepancy analysis has been conducted, information about the best approximation is used to create a Sound Model with information about the discrepancy between original and synthetic sound. This knowledge about the discrepancy between synthetic and original sound contained in the model is permitted to influence the generation of the next synthetic sound, whereby the difference between the new synthetic sound and the original sound sample can be reduced. By updating the model every time a sample has been processed by the encoder, the system is able to reduce the difference between original and synthetic signal to a minimum very quickly.


The decoder in the hearing aid contains an exact replica of the synthetic audio generator module in the encoder. Thus, information about the discrepancy-based best approximation is sufficient to provide all the necessary information for the synthetic audio generator in the hearing aid to be able to generate an exact copy of the synthetic signal in the encoder. In other words, the output signal generated by the hearing aid is a 100% synthetic sound identical to the synthetic sound generated in the encoder. The decoding sequence is presented schematically below.




Figure 6. The WidexLink decoder principle.

Transmission Robustness

A new, highly accurate and robust receiver has been developed for the Widex Clear product range to ensure safe transmission and low battery drainage. The accuracy of this new, patent-pending receiver enables us to operate with a low transmission power, which in turn contributes towards extending battery life.

Moreover, the modulation technique employed to send digital data over the wireless system also contributes to maintaing a high degree of robustness.

When sending digital data over a wireless system, a modulation scheme must be used. Modulation essentially determines how the digital information is sent through the radio frequency spectrum. One very commonly used digital modulation technique is Frequency Shift Keying(FSK). In an FSK modulation system, two frequencies are used to represent a binary "0" or a binary "1", respectively (see figure 7 below). So once the audio has been digitised, i.e., turned into a series of 0s and 1s, it can be transmitted by means of two different transmission frequencies which represent either a 0 or a 1. The receiver has to detect which of these two frequencies is being transmitted in order to determine if the transmitter is sending a 0 or a 1. The receiver then demodulates the signal by interpreting the frequencies received as either a 0 or a 1.

Figure 7. Illustration of the Frequency Shift Keying principle. In an FSK modulation system, two frequencies represent a binary "0" or a binary "1", respectively.


Traditional methods of wireless demodulation employ a simple two point sampling of the received wireless signal. This means that, in effect, the receiver relies on only two measurering points when it has to determine if the received signal is a "1" or a "0". Figure 8 below contains a model of the demodulation of a signal without noise.

Figure 8. Model of the demodulation of a signal without noise. Traditional methods of wireless modulation employ two points of sampling. In the example, the sample points indicate a rise. The signal will therefore be interpreted as a 1.

 

The demodulation method described above works very well with a clear signal and no noise. However, as illustrated in figure 9 below, using only two sampling points to determine if the transmitted signal is a 1 or a 0 can result in mistakes if noise is also present in the signal.

Figure 9. Model of the demodulation of a signal with noise. Signals can be wrongly identified when noise is present in the signal.

 

Consequently, Widex has developed a more secure variety of the FSK-method for the reception of wireless transmissions with a high degree of noise in the transmitted signals. The new method introduces a larger number of measuring points than the traditional two, which means that the receiver is able to determine with a much higher degree of certainty whether a received signal should be interpreted as a 0 or a 1.

Application

The new digital transmission technology is a central element in our new Widex CLEAR product range. It is used for the transmission of both data and audio signals in a large number of situations.

Transmission of audio

WidexLink is used for the transmission of audio signals from external devices to the hearing aids when the user watches TV, talks on his mobile phone, or listens to music.

Transmission of Audio via WidexLink
Typical Situation:	Sender and recipient:
TV	TV-Dex – Hearing aids
Hi fi	TV-Dex – Hearing aids
Mobile phone	M-Dex – Hearing aids
Personal audio device (Ipod, mp3 player, etc.)	M-Dex – Hearing aids

 

Transmission of data

WidexLink is also the employed in the transmission of data between remote control (RC-Dex) and hearing aid, and in the exchange of synchronization data between hearing aids (Inter-ear communication).

Transmission of data via WidexLink
Sender and recipient:	Feature:
RC-Dex - hearing aid	Remote control
Hearing aid - hearing aid	HA synchronisation Volume control Program shift
Hearing aid - hearing aid	IE coordination Compression Feedback cancellation Noise reduction
Hearing aid - hearing aid	WidexLink Surveillance Lost partner alarm

 

References:

Moore, B. C. J. (2006). An introduction to the psychology of hearing. Elsevier Publishing Company

www.bluetooth.com

 

 

 

Preserving the fundamentals of a natural sound experience

3D TruSound

Preserving the fundamentals of a natural sound experience

 

InterEar communication through a new, advanced wireless technology

Our new, proprietary WidexLink technology, which has been developed specifically for data exchange and audio streaming in a hearing aid system, offers new and exiting possibilities for exchange of data between hearing aids, and between hearing aids and external devices. The new technology enables the left and right hearing aid in a pair to share the information obtained by the opposite hearing aid, so that information from both ears is taken into account during signal processing. We call this data exchange InterEar communication.

InterEar communication is part of the foundation of the advanced features that comprise 3D TruSound. 3D TruSound is a new dimension of sound processing which aims at preserving the fundamentals of a natural sound experience and providing the highest possible sound quality at the same time.

The TruSound inheritance is excellent sound quality. With the introduction of 3D TruSound, a new dimension is added; namely the preservation of important localisation cues in natural hearing. In addition to the preservation of important sound localisation cues, coordinated noise reduction in difficult listening situations, and enhanced sound quality features are also central elements in 3D TruSounds.

3D TruSound includes the Digital Pinna – a feature which simulates the shadow effect of the outer ear in natural hearing. Furthermore, 3D TruSound also features TruSound Softener which can handle ultra short and extremely fast changes in sound level – for instance when somebody drops cutlery in a metal sink.

Figure 1. The3D TruSound features

 

The 3D TruSound features will be introduced in more detail in the following.

 

The Fundamentals of a Natural Sound Experience

Important sound localisation cues in normal directional hearing

The ability for hearing aid users to determine where sounds are coming from is important for a number of reasons, including safety (e.g. traffic sounds) and communication (e.g. locating a new speaker in a group).

Normal directional hearing relies on the comparison of auditory input from two ears. When an insect flies around our head we are able to determine where it is even with our eyes closed. That is only possible because we have two ears and a brain that help us coordinate the information from both sides of the head.

One of the primary psychoacoustic cues used for localising a sound source to the right or to the left is the split-second delay between the time when a sound reaches the near ear and when it reaches the far ear. This delay is referred to as the interaural time difference (ITD). The ITD will be at its maximum when the sound originates directly from the sides of the head. It is not a large difference; the maximum is around 0.65ms (Plack, 2005). When the sound is coming from the front or the back, the distance from the source to the ears is the same. Thus, there is no interaural time difference for sounds coming directly from the front or the back.

 

Figure 2. Sounds coming from the left or the right will reach the near ear a little sooner than the far ear. The ITD will be at its maximum when the sound comes directly from one side of the head.

 

Another psychoacoustic cue that is used for horizontal localisation is the interaural level difference (ILD). When a sound source is located to the right or the left of the head, the sound will have a greater intensity level when it reaches the near ear than when it reaches the far ear. This difference in sound pressure level at the near and far ear is an important cue for the localisation high-frequency sounds. The effect is predominant for high-frequency sounds because of their short wavelengths. At low frequencies, the difference in level at the two ears from sound coming from the side is low, because long waves easily flow around the head. A head is not a very big object for a low-frequent sound with a long wavelength, but it is a large obstacle for a high-frequency sound with a short wavelength.

Figure 3. Example of the interaural level difference (ILD) at different frequencies measured for one person. Notice the predominance in the high frequencies.

 

It is widely accepted (e.g., Middlebrooks & Green, 1991; Wightman & Kistler, 1992; Schub et al., 2008) that the ILD delivers the primary cue for horizontal localisation of sound sources in the high-frequency region and that the ITD delivers the primary cue for the localisation of low-frequency sounds. In this context, the split between high and low frequencies is approximately 1.5 kHz.

Research (Bogaerts et al., 2006) has shown that wearing a pair of uncoordinated hearing aids can have a destructive effect on the cues used for localisation and consequently reduce the localization abilities of the hearing aid user. However, with the new technology in CLEAR440, it is possible to preserve important psychoacoustic cues.

InterEar TruSound compression – preserving important localisation cues

In a normal compressions system, gain changes depending on the input level. Thus, when you are wearing an uncoordinated set of hearing aids, gain will be prescribed independently to the near and far ear on the basis of the input level at the individual ear. A sound coming from the side will have less intensity when it reaches the far ear than when it reaches the near ear. And because the sound is lower in intensity when reaching the far ear, more gain will be provided at the far ear than at the near ear. This means that the natural interaural level difference will be compromised. However, by coordinating the gain changes on the two sides, the natural ILD can be preserved. This is what the InterEar TruSound Compression does.

Specifically, in CLEAR440 hearing aids, the communication between two coordinated aids ensures that the input levels at the hearing aids are constantly compared (21 times per second), and that the compression response is adjusted accordingly to reflect the difference in input level at the two ears. In practical terms, this means that both ears will receive the same amount of gain, which will depend on the basis of the input level in the near ear.

 

InterEar volume shift and program control – for the preservation of important sound localisation cues and ease of use

The main purpose of coordinated compression is to preserve the ILD. However, if the user turns the volume up or down or changes program at one side only, the ILD can no longer be preserved. In order to prevent that the attempt to preserve the natural ILD is obstructed, InterEar volume shift and program control is introduced in CLEAR440 hearing aids. The InterEar volume shift and program control ensures that if the user changes the volume on one hearing aid the volume of the other hearing aid will also change accordingly. If the users changes program on one hearing aid, the same program will be chosen automatically by the other hearing aid. InterEar volume shift and program control is switched on as default in CLEAR440 hearing aids, but can be switched off by the hearing care professional in the fitting software.

Another major advantage of the InterEar volume shift and program control is that it makes it a lot easier for the hearing aid user to adjust the volume. Users wearing an uncoordinated pair of hearing aids have to adjust each hearing aid separately every time they need to turn the volume up or down or change program. With a pair of coordinated CLEAR440 hearing aids, the user only has to make the adjustment once, which is likely to be appreciated by many hearing aid users.

There may be situations where the hearing aid users would prefer to have different programs in their hearing aids. To accommodate this, a selection of compound packages is available in CLEAR440. These include:

• Master – Telecoil
  
• Master – Microphone+ Telecoil
  
• Master – Reverse focus
  
• Master – Zen
  
• Master – Audibility Extender
  

 

InterEar Speech Enhancer - Coordinated noise reduction in difficult listening situations

Communicating in a noisy environment is one of the most challenging situations for hearing aid users. Many users experience difficulties focusing on one speaker and leaving out the rest. The Speech Enhancer can be very helpful in that situation, and with the introduction of the WidexLink technology the situation can be improved even further.

The Speech Enhancer system is available in Widex high end hearing aids. The system is based on the standardised measure of SII (Speech Intelligibility Index) (ANSI S3.5). The system is unique in that it is able to take the hearing loss into account and optimise speech intelligibility by means of a constant calculation of the SII during noise reduction.

The Speech Enhancer contains a fast-acting mechanism which is able to add gain to frequency areas with speech to further optimise speech intelligibility. In CLEAR440 hearing aids, this fast-acting mechanism is coordinated to ensure that it is active on the side with the most dominant speaker. By exchanging important percentile data over the WidexLink, two CLEAR440 hearing aids are able to make a decision on whether to activate the fast-acting gain application mechanism and on which side to do this. This way, the Speech Enhancer systems will no longer base its decision to act on one-sided data input, but on data input on the sound environment on both sides of the head. Only on the side where speech is dominant will the speech enhancer actively work to preserve speech audibility by adding gain to frequency regions important for speech. On the opposite side the noise reduction system will work to keep the noise below the threshold of the listener using his or her hearing threshold data in the calculation. In practical terms, the coordination between hearing aids means that in a cocktail party situation with many speakers, the InterEar Speech Enhancer in CLEAR440 supports the singling out of the dominant speaker.

Digital Pinna – re-creating the natural pinna shadow effect

The ear has some natural directional characteristics, mainly due to the physical presence and shape of the pinna. One example is the pinna shadow effect. Sounds coming from the front reach the ear canal almost directly, whereas sounds coming from behind are obstructed by the pinna and are thus somewhat attenuated before they reach the ear canal. This pinna shadow effect mainly affects the region around 2 to 5 kHz, where sounds coming from behind are attenuated by 3-4 dB relative to sounds coming from the front. This natural 3-4 dB difference is an important cue for the listener to know whether a source is in front or behind.

Microphone location is known to have a negative impact on the ability to determine if a sound is coming from in front or from behind. Front-back localisation is especially a problem for users with behind-the-ear (BTE) hearing aids, because the location of the microphone essentially offsets the normal localisation cues provided by the pinna (the outer ear).

For example, Westermann and Tøpholm (1985) found that BTEs give poorer localisation than ITEs, in particular with respect to front-back confusions. A BTE hearing aid captures the sound at the position of its microphone(s), i.e. above and behind the pinna. This means that the pinna shadow effect is not preserved in the signal that the HA provides, and consequently the HA user loses some of the ability to localise vertically, and to distinguish front and back.

 

Figure 4. The average pinna effect measured over 45 heads. The 3-4 dB difference between sound coming from behind and from the front is seen in the 2-5 kHz frequency region.

 

As mentioned, the spectral shaping provided by the pinna is an important cue for front/back localisation. One way to improve localisation for hearing aid users with BTEs, therefore, would be to attempt to re-create this shaping through processing of the input signal. This is precisely what Digital Pinna in CLEAR440 does.

A series of developmental experiments have shown that the pinna shadow effect can be simulated by introducing a restriction on the adaptive locator. More specifically, the natural attenuation of sounds coming from behind can be re-created by setting the frequency bands from 2 kHz and up (bands 10-15) in fixed directional mode (i.e. in the hypercardioid pattern, which picks up sound at the front and eliminates most sound from the sides and rear), while leaving the lower bands (1-9) in omni-directional mode.

Figure 5. The microphone patterns of Digital Pinna. The lower bands (1-9) are in omni-directional mode, while the upper bands (10-15) are in fixed directional mode (i.e., in hypercardioid).

 

The developmental experiments were carried out using four normal-hearing listeners as subjects. 12 loudspeakers were set up in a 360° horizontal circle around the test subject, with a radius of 1.2 meters and 30° between the loudspeakers. The setup is shown in the figure below.

Figure 6. The loudspeaker setup in the developmental experiments exploring Digital Pinna.

 

As stimuli, 4 different recordings of a wooden rod (120cm) that is dropped on the floor were used. Each of these 4 recordings was presented once from each of the 12 loudspeakers, giving a total of 4*12=48 presentations (in randomised order) for each localisation test. The test subjects were instructed to indicate from which loudspeaker each presentation was coming. The Digital Pinna was compared with the omni-directional mode and with a fixed locator (the one giving maximum directivity).

Figure 7 below shows the main results for the four different tests where head movements were not allowed. Digital Pinna resolved 80% of the front-back confusions that were made in omni-directional mode. This performance is slightly better than (or at least similar to) the fixed directional system. In addition, Digital Pinna did not degrade the horizontal localisation as the fixed directional system did, and Digital Pinna had the best horizontal localisation in the frontal plane.

 

 

Figure 7. Main result of a developmental experiment comparing front-back confusion with Digital Pinna, omni-directional and fixed directional mode. Head movements were not allowed in this condition. The left panel shows how many front/back confusions were made (in %) in each mode. The right panel shows by how many degrees horizontal (left-right) localisation errors deviated from the correct response angle on average.

 

When head movements were allowed, the Digital Pinna was clearly best overall. The results are displayed in figure 8 below. There were almost no front-back confusions with Digital Pinna compared to omni-directional and fixed directional mode, and the horizontal localisation did not show large errors in the back, like the fixed directional mode did.

 

Figure 8.
Main result of a developmental experiment comparing front-back confusion with Digital Pinna, omni-directional and fixed directional mode when head movements were allowed. The left panel shows how many front/back confusions were made (in %) in each mode. The right panel shows by how many degrees horizontal (left-right) localisation errors deviated from the correct response angle on average.

 

 

The results from the developmental studies indicate that Digital Pinna restores the ear's natural effect (pinna shadow) in BTEs, and thus the user's ability to distinguish between sources in front and back. The results also showed that it did so without degrading horizontal localisation (which the fixed directional system may). Furthermore, it enables the user to improve localisation by taking advantage of active head movements (which the fixed directional system does not).

Importantly, the microphone system remains adaptive when Digital Pinna has been activated. In quiet listening environments, the lower bands (1-9) will be in omni-directional mode, whereas the upper bands (10-15) will be in hypercardioid as shown in figure 5. In noisy listening conditions, the directionality of both lower and upper bands will increase to yield optimum speech intelligibility. The microphone mode of the lower bands may adapt any characteristic from omni-directional to bipolar, while the upper bands may move from hypercardioid towards bipolar as the signal-to-noise ratio worsens.

 

Advanced Sound Quality Features - Taking high sound quality a step further

A discussed above, one of the key elements in the CLEAR440 hearing aid is a collection of features designed to preserve important psychoacoustic cues. Another cornerstone in the CLEAR440 product family is a collection of enhanced sound quality features. These features will be described in more detail in the following.

InterEar feedback cancelling

To be successful, a feedback system must be effective in terms of eliminating feedback. The precision with which it can determine if the signal really is a feedback signal is also important.

Experience has shown that the Multi-directional active feedback cancelling system is extremely efficient in controlling dynamic feedback problems. No matter if the hearing aid user is talking on the phone, hugging a friend, or putting on a hat, the Multi-directional active feedback cancelling system has been designed to ensure that whistling does not occur.

With the introduction of CLEAR440, we have managed to make our industry leading system even more precise. Specifically, when an external, autocorrelated sound like a whistle or an alarm is picked up by the hearing aid, the InterEar coordination between the hearing aids means that they are able to compare detected sound from both sides of the head. If the feedback-like signal is the same on both sides, it can be deducted that it is an external sound rather than a feedback signal which has been detected. Thus, with InterEar feedback cancellation, we are able to avoid gain regulation when it is not necessary as a result of "false positives". However, if a feedback-like sound is only found on one side of the head, the system will deduct that it is feedback which needs to be handled.

 

Enhanced bandwidth

Audio bandwidth is one of the key factors in maintaining a high sound quality. Thanks to the new technology in the CLEAR440 product range, we are able to offer an exceptionally broad audio bandwidth in models with a Clearband receiver, stretching from 70 Hz to 10.5 kHz in the music program, and 100 Hz to 11.2 kHz for digitally transmitted sound. This is industry leading.

One area where a broad audio bandwidth makes a clear difference for hearing aid users is when they listen to music. The high frequencies provide ambience and brilliance to the sound. Thus, the sound experience will be somewhat richer with an upper bandwidth of 10.5 kHz when listening to a hi-hat or cymbals, for instance. Similarly, an audio bandwidth stretching as far down as 70 Hz will produce a fuller bass.

 

TruSound Softener

The advanced sound quality features of 3D TruSound also include the TruSound Softener. The purpose of the TruSound Softener feature is to make impulse sounds, such as rattling porcelain or hammer blows, less annoying without removing them from the surrounding sound environment or making them unnaturally soft. The TruSound Softener is described in more detail in a separate whitepaper entitled TruSound Softener: A new algorithm for detecting and handling impulse sounds.

 

Summary

With 3D TruSound, Widex takes sound processing a step further. 3D TruSound introduces a new dimension in sound processing – the preservation of the fundamentals of a natural sound experience. This is achieved by taking signal analysis data from the opposite hearing aid into account in the processing.

The new proprietary WidexLink technology in the CLEAR440 product family makes it possible to preserve a number of important psychoacoustic cues used for determining where a sound is coming from.

Our attempt to provide a realistic listening experience for the hearing aid user has lead to the development of a comprehensive collection of features, including

• Digital Pinna, which has been developed to support front-back localisation
  
• InterEar TruSound compression, and InterEar volume shift and program control, which contribute to the preservation of psychoacoustic cues used for localising sound coming from the sides.
  
• InterEar Speech Enhancer, which may help hearing aid users focus on the dominant speaker in noisy situations
  

Another cornerstone in the CLEAR440 product family is a collection of enhanced sound quality features. The result of our latest effort to provide the best possible sound quality include

• The TruSound Softener, which has been designed to detect and handle impulse sounds
  
• Extended bandwidth in both high and low frequencies
  
• InterEar feedback cancelling which minimises the risk of continuous steady sounds being attenuated by the feedback system because they are mistaken for feedback
  

  
   

 

References

ANSI S3.5. 1997. American National Standard: Methods for the calculation of the Speech Intelligibility Index.

Algazi, V. R.; Duda, R. O.; Thompson, D. M. & Avendano, C. (2001). The CIPIC HRTF Database.
In proceedings of IEEE Workshop on Applications of Signal Processing to Audio and Acoustics, 99-102.

Middlebrooks, J. C., & Green, D. M. (1991). Sound localization by human listeners. Annual Review of Psychology, 42, 135-159.

Plack, C. J. (2005). The sense of hearing. New Jersey: Lawrence Erlbaum Associates

Schub, D. E., Carr, S. P., Kong, Y., & Colburn, H. S. (2008). Discrimination and identification of azimuth using spectral shape. Journal of the Acoustical Society of America, 124(5), 3132-3141.

Van den Bogaert, T., Klasen, T., Moonen, M., Van Deun, L., & Wouters, J. (2006). Horizontal localization with bilateral hearing devices: Without is better than with. Journal of the Acoustical Society of America, 119(1), 515-526.

Westermann, S. & Tøpholm, J. (1985). Comparing BTEs and ITEs for localizing speech. Hearing Instruments, 36(2), 20-24.

Wightman, F. L. & Kistler, D. J. (1992). The dominant role of low-frequency interaural time differences in sound localisation. Journal of the Acoustical Society of America, 91(3), 1648-1661.

Widex Company Film

Widex Ireland is pleased to announce the launch of FUSION, part of the successful CLEAR™440 series

Widex is pleased to announce the launch of FUSION, part of the successful CLEAR™440 series.
FUSION is designed to give hearing care professionals a flexible solution in fitting a wide range of users. The Fusion will be launched to the Irish Market at a launch event this coming weekend in Denmark.

The Fusion is unique in giving Dispensers the opportunity to choose from three different receivers, as well as various ear-tip and custom earmoulds, to suit most types of hearing loss.
The output of FUSION can be extended up to 138 dB SPL using an industry-first, patent pending Output Extender. And all this wrapped in a much smaller housing than standard models.

Technological features

FUSION comes with a raft of sophisticated technological features to increase user satisfaction, including:

 
C4-FS

• Phone+ that for the first time allows users to hear both mobile and landline phone calls in both hearing aids without delay
• a small housing - yet with room for a 312 battery, providing long life and excellent performance
• an industry-first Output Extender custom earmould (patent pending) maximises the output of FUSION up to 138 dBb SPL
• a new and improved nano-coated microphone cover that significantly reduces wind noise
• a new stable and robust telecoil designed specifically to fit in FUSION’s small housing

Fusion will be launched for order in Ireland in January

Patient Retention and Customer Referral, Article four, The Consultation.

The Consultation is a combination of audiometric testing, psychological profiling, counselling and sales process. It is the time that you get to impress upon every prospective Patient your own brand. So if you feel you are and indeed position yourself as, a caring, competent, friendly, professional, this is the time to display that. The consultations is made up of several stages, each of these stages are important in the process no matter whether you are in private or public practice.

Whether the Hearing instruments you provide cost large denominations of somebody's ready cash indeed are free. You will be every day selling a product to somebody who does not really want it. If you are not selling the product, you are not serving your Patients to the best of your abilities. In the public service, when that Patient says he has difficulty wearing his aid because of this or that.If you have not qualified that Patient properly, you will not understand if there is an underlying reason to his or her intransigence.

Perhaps it is about cosmetic or psychological perceptions, not the excuse that is being given. If you do not qualify somebody you simply do not know and cannot counsel for the true objections. In private practice, it is imperative that you qualify and overcome objections because otherwise, you don’t eat. The simple calculation of No take care Patient= No food+hungry belly, tends to focus the mind quite amazingly.

The key to success is to ask, stop and listen, listen again and then listen some more. Do not spend the time that your Patient is speaking formulating what you will say next, listen, listen carefully. Because if you do, you will pick up not only what they are saying, but more importantly, what they are not saying. Often what a Patient is not saying is the truly important information when it comes to rehabilitation and counselling.

A well structured consultation with clear procedure allows you to begin the engagement with your Patient, it is the foundation that any and all Patient Retention and Customer Referral strategies are built on. If you do not succeed in the connection at this stage, it is harder to truly build a strong and loyal engagement.

Consultation Procedure

Your consultation is the core of your selling cycle, it should be designed with this in mind, the core principles are approach, i.e. intro and icebreaking, qualify, i.e. medical history and testing, commitment, i.e. the acceptance of loss and the commitment to do something about it, close, i.e. the taking of an order and explanation of the process, consolidate, i.e. consolidation of the sale and re-affirmation of the decision. Each of these stages in the consultation is important to the structure and the goal, the separate principle of Support is quite probably the single biggest factor in a consultation. Does the Patient have support with them and more importantly, is it the right support?

Your consultation structure should be something like this;

Introduction: Who you are.

Icebreaking: The weather, holidays, current events.

Taking of details: Name, address, date of birth, phone number etc.

Medical History: The taking of a detailed medical history with questions pertaining specifically to the referable conditions.

C.O.S.I.: The taking of a cosi, gaining clear knowledge of at least three problem areas.

Otoscopy: Examine the Patient’s ears

Audiometry: testing of the Patient’s hearing.

Explanation: Explanation of the Patient’s hearing loss and its effect on their lifestyle.

Live demonstration: Demonstrate the aids to the Patient

Options: Always give three hearing system options.

After your introduction and ice breaking you should begin to inform and explain the purpose of what comes next, this begins to remove the fear of the unknown for the Patient and explains to them your procedure and the reasons behind it. The structure is simply the best way to run a consultation because you understand where you are and what you have done easily if you get side tracked by Patient questioning.

Approach

Ice breaking topics can be as simple as the weather or holidays, recent news stories etc, remember that if you give a little you will get a little. In other words tell them about your hobbies or travel etc.

Qualify

Qualifying is a process that begins with the taking of personal details and carries on all through until you are about to start your testing procedures. Its primary purpose is to establish your Patient’s problems and motivation levels.

What are you trying to achieve?

· Is there anything medically wrong with the Patient’s hearing?

· What are the Patient’s handicaps?

· What is affordable for the Patient?

· Does the Patient accept that they have a problem and are the committed to doing something about it?

· Is a hearing system the solution?

The methods you choose to address a particular topic very much depend on how you assess your Patient’s potential attitude to that topic. You should rely on your inter-personal skills to judge these situations and formulate the question in the least confrontational way.

After every question you must think to yourself do I need to ask another question, respond and clarify or educate or move on. You should only move on when you are happy that every question for you and your Patient has been answered. You must let the discussion take its natural flow bringing it back to its central theme as you go. You may find that you have introduced a topic, however the Patient has responded unexpectedly or raised a new issue that you feel needs to be dealt with. Deal with it but eventually find a route back to the original topic so it can be closed.

With some Patients it is important to clarify what they are asking you, they may have asked a question that you feel they already know the answer to or have some knowledge of. You may ask them a question that will help you clarify what the underlying concern is. It is only when a Patient’s underlying concerns are answered that they will be able to move on to acceptance of treatment. Any advice that you give at this stage of the consultation will be seen as just that advice. Later in the consultation it will be seen as selling. For that reason alone it is important to cover sensitive topics at this stage, price range, technology level etc.

Your questioning technique should be to use open ended questions, questions that cannot be answered by a yes or no. Use words such as when, where, how, why, questions that begin with these words are answered with statements. It is important that you listen to these statements, you may feel that you have heard it all before, however this may be the first time that this Patient has vocalised these problems. The answers to your questions may also involve a lot of emotional content for your Patient, do them the courtesy of listening, take notes and make comments that lets the Patient know you are listening.

The COSI is probably one of the most powerful tools available to encourage emotional engagement with your Patient, it is imperative that you handle it well. Ensure that you cover each problem area intensively, get all the details and record them. Your Patient will tell you exactly what the issues are and the effects that they are having on their life. Listen to them, do not interrupt and appreciate that this person may be vocalising deeply emotional problem areas.

The topics that need to be discussed during the Consultation are as follows:

· Client details and background.

· Areas of difficulty, Lifestyle Issues.

· Previous aid use.

· Hearing aid style/ attitude to wearing hearing aids.

· Your company and service.

· Price.

· Levels of technology.

· Monaural versus binaural.

· Medical aspects.

Price of hearing aids are always a bone of contention, most Patients will bring you to this topic as soon as they accept that they want or need a hearing aid. The best explanations should include

· Your company and back up service.

· Levels of technology.

· Research and development.

· Lifestyle considerations.

· Expectations of Patients.

· Choice.

· Cosmetics.

· Acoustical considerations.

· Complex nature of hearing loss.

· Complex nature of re-habilitating to hearing aids.

· Finally You, their own individual professional.

Explanation of technology levels

This is where you can begin to link hearing aid features as solutions to the difficulties the Patient has informed you of as well as helping them to fully understand why the prices of hearing aids differ depending on how many of these features they want in their hearing aid. The easiest way to deal with this is to discuss two overall concepts.

Level of technology

Whilst it is true that you get what you pay for, it is important that Patients understand that high end technology is not necessarily the best solution for them. It is what is most appropriate for their lifestyle that is of the greatest importance. They need to understand your role in determining the options and that it is not simply to get them to spend money on expensive option. Illustrate your explanations at all times, a combination of visual and aural information is best for communication of these matters. The visual cues remain to mind longer and assist the Patient to understand more clearly.

Signal to noise ratio

All hearing aids are designed to improve the signal to noise ratio. Explain this to your Patients, you can then relate this to levels of technology thus: Entry = Improvement of Signal, Medium = Reduce the noise and High = Does both.

All levels of technology have the same core technology elements and these can and should be referred to, to begin the process of equating problems for the Patient with the solutions you can offer. These can be summarised as thus:

· Compression.

· Multi program.

· Multi channel.

· Noise reduction.

· Directionality.

· Feedback Suppression.

Be familiar with these concepts and formalise an explanation for each, one in your own terminology is best; a standard generic explanation will come across as robotic or worse. A statement that is formulated by yourself using your own terminology has the ring of truth about it.

Monaural versus binaural

A common misconception among Patients is that one hearing aid will suffice. If you intend to be able to ask the Patient to buy two hearing aids, they will need to understand why you are making that recommendation. The concepts that you will need to discuss are:

· Benefits of binaural hearing.

· Advantages and disadvantages of monaural hearing.

· Auditory plasticity and rehabilitation.

You need to become familiar with these concepts and again formulate explanations in your own terminology. Use visual aids if available to reinforce the information you are imparting, or draw diagrams. Aural information in conjunction with visual cues is much more powerful than aural information alone.

The Importance of having support

There are four main reasons for the need for Patient support:

Client Confidence

· Many of our Patients feel much more at ease if they physically have somebody else with them during the consultation.

Informed Decision

To be able to make a decision at the end of a potentially long consultation, where a lot of information has been imparted, it is of great assistance for the Patient to have another person present who can assist their decision making process.

Handicap Familiarity

· Most hard of hearing Patients underestimate the true handicap their hearing disability has in their life. Having a person present who can comment objectively on the degree of handicap is extremely important to the Patients acceptance of the need for action.

Consolidation

· Perhaps the most important time for the Patients support is after you, the professional, have left (or they have left your clinic). It is vital that the support reinforces the notion that the right decision was made, thereby overcoming the most human of reactions ‘buyers’ remorse.

For these reasons it is of great importance that the Patient is accompanied by support and more importantly, you engage and educate that support during the consultation process.

Explanation of an audiogram

The explanation of the audiogram is perhaps one of the most powerful parts of the consultation, for many Patients it is the moment of realisation, of irrefutable fact that they have a hearing loss. It is essential that the explanation of the audiogram and the hearing loss is delivered with care. If you give too little importance to your explanation, the Patient will not understand why they should care about their hearing loss or take action. If you give too much emphasis you may leave the Patient in a state which precludes them from accepting assistance.

The level of detail and type of language you use will vary depending on your assessment of the Patient’s behavioural type and emotional state. The content however should remain unchanged and there are key points the Patient should understand before you move on:

· Describe the audiogram and what the axes represent.

· Describe normal levels of hearing.

· Describe complete speech deafness.

· Compare your Patient’s thresholds to normal thresholds.

· Classify their hearing for low pitches and vowels versus high pitches and consonants.

· Illustrate what the symbols represent with the use of anatomy diagrams.

· Relate their thresholds and phoneme perception to their problem areas.

· Explain what a hearing aid will do to sounds that are below the thresholds.

· Explain what a hearing aid will do to sounds above the thresholds.

Demonstration of a system.

The demonstration of a hearing system is again one of the more powerful moments of the consultation process. It is the moment where you have the opportunity to wow your Patient. This is your opportunity to consolidate the ideas you discussed earlier and allow the Patient to make an informed decision with regards to technology and price.

Your demo should be based on the following structure:

· Familiarisation.

· Monaural/binaural preference.

· Hearing in noise.

· Additional features.

Familiarisation: Especially if this is your Patient’s first experience of hearing aids, but also applicable if you are changing the Patient’s prescription, the sound you first introduce to the Patient will be different, unusual or may even be uncomfortable. You should adopt the approach of telling them what they are hearing and talking them through to relieve the stress, but not the impact. The important things at this time are that you check and adjust overall loudness, tell them it will be louder, but it should be comfortable.

Check and adjust clarity, it should be crisp and clear without becoming too harsh or irritatingly metallic. Check and adjust where possible occlusion, explain occlusion and why it is happening, test tips etc. Once you have achieved clearer comfortable hearing you can begin to resolve the Patient’s problems. Relating back to their problem areas as much as possible, but resorting to common difficulties where necessary, you should encourage the Patient to begin to converse with their support and demonstrate the following:

· Hearing normal conversation in a quiet room.

· Hearing speech from short distances.

Monaural/binaural preference: Your Patient will already have inferred or directly told you if they prefer monaural or binaural amplification, and if it is only one ear, which ear they prefer. All you have to do is show them the difference and ask the question:

· While you are talking to the Patient, explain that you are turning off one ear at a time and then returning to both.

· Explain that hearing is better than nothing with only one aid, but it instinctively does not feel as natural as with two.

· Ask them do you hear better with an aid in your left ear or right ear, or both.

Hearing in noise: Your Patients will commonly tell you that it is not one noise but a combination of many that is most difficult to hear in. Use good quality speakers in your practice and play some of the numerously available sound files. Again it is vital that you explain what you are doing before you start adding noise to your demonstration:

· Relate the importance of this part of the demonstration to the conversation you had with regards to technology earlier in the consultation.

· Explain that some people benefit more than others from noise suppression systems and that this is their opportunity to assess if they would like to have it in their hearing aid or not.

· Establish how well your Patient can hear you face to face in noise with no features active, omnidirectional and noise suppression off.

· Activate the features and tell them what the hearing aid is doing and how it is helping them hear you with less effort.

· Relate the situation clearly back to their earlier mentioned problem areas.

Additional features: The minimum requirement for this part of the demonstration is to ensure your Patient understands directionality, but you may add as required a demonstration of as many features as you have identified will be of importance to your Patient, e.g. additional programmes for music, feedback cancellation etc.

All the way through the demonstration you are showing the Patient that you can solve their problems with the right equipment, you are also displaying to them the concept of technology matching to lifestyle needs. This is key to their understanding and thought processes, it also allows you to model realistic expectations.

 

 

Patient Retention and Customer Referral, Article three, Consultation Room

In this the third article I would like to move on to the consultation room, initially I would like the cover the environs of the room but also the consultation practice itself. I shall attempt to cover the room and the structure of the consultation in this article and explore the consultation in a deeper manner in the next. We have reached the consultation room, the inner sanctum, the place where we have traditionally thought the real action occurs. It is indeed all of those things, but I hope I have showed in my previous articles that it is indeed not the whole story when it comes to Patient journey and engagement.

When you enter your consultation room, take a good look around it and ask yourself, what does this room say about me and my day to day practice? I undertook this exercise after I had been in practice for a while, initially when I started my practice day to day thoughts just centred on my audiometery and hearing instrument fitting, my main worry was that I did not make a mess of these elements. After I had settled down and realised I was the king of practice, sorry can't resist. I began to concentrate on the sales elements that we all undertake in our consultations, slowly but surely finding my consultation style. With this done I began to look at my consultation room, it's appearance and design and how I could change that to engender the perception I wished and allow me to connect with my Patients.

I realised that my consultation room was a mess, between hanging cables, the bane of our existence these, tackle boxes full of tubing etc the usual day to day detritus of a practice. I also realised that I sat behind a desk, talking to my Patients, when I thought about this clearly it seemed immediately the wrong position to be in if I was trying to engage with my Patients. So with this in mind, take a long look at your consultation room, store your cables and paraphernalia out of site, whatever you use during one consultation, put it away afterwards. The only things that should be visible on your desk are the fixed apparatus that we use every day. An audiometer, a computer monitor and a keypad, your otoscope and very little else.

If you do not have proper storage, get some built in or indeed buy a nice piece of furniture to store everything in, keep it tidy and keep everything in its place. There is nothing worse than searching like an idiot for something whilst your Patient looks on. Change your desk aspect; place it in order that the Patient and their significant other sit beside you as opposed to across from you. This allows a greater feeling of engagement with your Patient, it also closes the physical gap between you and them, allowing the Patient to relax somewhat and as the consultation moves on to emotionally engage with you in an easier manner.

Position the equipment on your desk including your computer screen and keyboard in an aspect that always allows you to be looking towards the Patient and the significant other. This allows constant engagement with both of them, if you want real long term commitment from your Patient you will need to engage with their companion/family also. This is imperative; engagement with the Patient's companion will increase the commitment to you and your advice from the Patient. That engagement needs to start from the initial consultation, if not during the actual making of the appointment.

The Walls of your consultation room also need to be looked at strongly, do you have anatomical display posters, and are they properly farmed and hung? Again do you have manufacturer posters, are they properly framed and do you update them? If you do indeed have manufacturer posters, why do you? I am still unsure if it is indeed a good idea to have such marketing elements in a consultation room, having those elements does not speak of an independent clinician. Having half a dozen of the different Manufacturer posters speaks of a supermarket, I am not sure if there is an in-between so hang a nice relaxing picture instead and of course your qualification.

Keep it clean and tidy, tidy up during the day if need be, you wish to be perceived as a consummate professional with a deep sense of empathy and caring, you need to display that consistently. Before you open your mouth, your practice initial communications and the deportment of your staff has already said a great deal.

In order to have a maximum effect, the actual consultation needs to be well planned and enacted, in the planning stage you need to think strongly about Patient perception and psychology and what indeed you hope to achieve. Whilst Audiologists or Dispensers are mostly caring and motivated by the opportunity to make a real difference to somebody's life, we got to eat, so assisting somebody is balanced with making a sale. Most of our Patients, do not want to buy, in fact the last thing they generally want is hearing aids. It is with this fact in mind that we see the challenge we face every day, how do you convince somebody that they need a product they do not want without falling back on the optimal negotiation position (the head lock for those who don't know).

With these stark facts in mind you need to design a consultation that allows you to convince them of the benefits of a device without any perception of a hard sell. This is possible, not only is it possible but there are gifted Dispensers doing it with effortless ease every day on instinct, for you and me I am afraid we have to work at it. You may think that planning a consultation to influence people surreptitiously is underhanded, but if like me, you think you are an excellent clinician who deeply cares for your Patient. Does it not follow that you should undertake every possible action and explore every avenue to ensure a Patient comes into and stays in your care?

The stages of a consultation are qualifying to see in fact if a Patient has a loss, overcoming objections to meet any queries, worries or objections that a Patient or indeed the significant other has and closing the sale. The consultation does not necessarily fall in that order, the initial part of the consultation should be a mixture of qualifying and overcoming objections which leads to testing and then the close. Think deeply about this process, come to conclusions and then design a medical record card that follows the flow that you have chosen and includes headlines that cover all the questions that you wish to ask and indeed answer.

For instance, any attitudes to hearing aids should be assessed before the test, because any conversations that you have around BTEs versus ITEs, binaural versus Monaural, lifestyle needs, medical contraindications to certain devices etc will be seen as advice at this stage. After the test it will be perceived as you selling your point of view. Every professional should use the COSI and integrate it into their consultation, I have written of it before and I still think it is one of the most powerful tools which encourages emotional connection with your Patient and allows you to really understand their lifestyle needs. It also allows you to clearly manage their expectations and to agree a roadmap for your Patients care. All of this from an A4 piece of paper that practically explains itself.

Client Orientated Scale of Improvement, COSI and its uses for your practice.

Emotional engagement is the key, when you make an emotional connection with your Patient it allows them to trust you and feel that you not only understand them, their needs and problems, but you care enough to try your damndest to fix those problems to the best of your ability. This is the key to Patient retention, the crux of the matter, if a Patient feels cared for, that they are not viewed as just a wallet with cash in they feel that they are in a worthwhile relationship. If they feel that they are in a worthwhile relationship, they will stay in it, not only will they stay, but they will tell others about the wonderful caring new friends they have found.

The point is simple, to keep a Patient and gain their friends, treat them like a human being, treat them like they matter to you, their problems matter to you and more importantly the outcomes of their care matter to you. Because these are the things that matter to them.